Analysis of after hours primary care pathways
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Analysis of after hours primary care pathways
National Association of Medical Deputising Services November 2016
Analysis of after hours primary care pathways
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Contents
Glossary v
Key observations vi
Executive summary viii
1 Introduction 16
2 After hours primary care in Australia 17
2.1 After hours primary care 17 2.2 Access to primary care 18 2.3 Delivery of after hours primary care 23
2.3.1 Emergency departments 23 2.3.2 Ambulance 26 2.3.3 Extended and ‘after hours only’ clinics 28 2.3.4 Healthdirect Australia 28 2.3.5 GP Access Schemes 30 2.3.6 After Hours Home and ACF Visits 30
3 Patient Pathway Analysis 32
3.1 Comparison context 32 3.2 Financial evaluation 34 3.3 Financial evaluation results 35 3.4 Other impacts 37 3.5 Summary 39
Appendix A: Patient pathway analysis 40
A.1. Analytical framework 40 A.2. Emergency department 41
A.2.1. Financial cost 42 A.2.2. Other costs 43
A.3. Ambulance 44
A.3.1. Financial cost 44 A.3.2. Other costs 50
A.4. Extended and after hours only clinics 50
A.4.1. Financial costs 50 A.4.2. Other costs 52
A.5. Healthdirect Helpline 53
A.5.1. Financial Costs 53 A.5.2. Other Costs 55
A.6. Hunter GP Access 55
Analysis of after hours primary care pathways
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A.6.1. Financial Costs 56
A.7. After hours home and ACF visits 57
A.7.1. Financial cost 57 A.7.2. Other costs 58
Appendix B: Patient pathways analysis including admitted patient
costs 60
B.1. Emergency department (with admitted patients) 60
B.1.2. Summary: Emergency department presentation costs,
including admitted patient costs 62
B.2. Ambulance 64
B.2.1. Hospital emergency departments 64
B.3. Impact on other patient pathways 66
Appendix C: NAMDS members 67
Limitation of our work 68
General use restriction 68
Analysis of after hours primary care pathways
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Charts
Chart 2.1: MBS expenditure on after hours versus in hours primary
care ............................................................................................. 20 Chart 2.2: Home and ACF visits: in hours and after hours (per
100,000 people) ............................................................................ 22 Chart 2.3: Workforce participation: males and females 1990 to 2016 ...... 23 Chart 2.4: Public hospital emergency department presentations in
Australia by triage category ............................................................. 25 Chart 2.5: Change in the proportion of emergency department
presentations by category ............................................................... 26 Chart 2.6: Number of ambulance patients in Australia .......................... 27 Chart 2.7: Patients arriving by ambulance to emergency departments
by ATS triage category (‘000s) ......................................................... 28 Chart 2.8: Healthdirect nurse-triage call recommendations/advice .......... 29 Chart 2.9: Healthdirect after-hours GP helpline
recommendations/advice................................................................. 30 Chart A.1: Proportion of Government grants and contributions to
ambulance revenue ........................................................................ 48
Tables
Table 3.1: Patient cohorts considered in this analysis ........................... 34 Table 3.2: Comparison of patient pathway costs that include and
exclude admitted patient costs ......................................................... 35 Table 3.3: Cost per patient of accessing alternative pathways................ 36 Table A.1: Descriptions of patient cohorts .......................................... 41 Table A.2: Cost of emergency department presentations by triage
category and age cohort.................................................................. 43 Table A.3: Emergency department cost by patient cohort (non-
admitted) ..................................................................................... 43 Table A.4: Scheduled ambulance service fees ..................................... 47 Table A.5: Cost per patient – non-emergency and treat no transport ...... 48 Table A.6: Non-admitted patient costs by age cohort and triage
category (arrived by ambulance) ...................................................... 49 Table A.7: Total non-admitted patient costs (arrived by ambulance) ....... 49 Table A.8: Weighted average cost of ambulance pathway ..................... 49 Table A.9: Ambulance and emergency department per patient costs ....... 50 Table A.10: Extended and after hours only clinics cost by State and
Territory ....................................................................................... 51 Table A.11: Total per patient cost of extended and after hours only
clinics .......................................................................................... 52 Table A.12: Healthdirect Helpline costs .............................................. 55 Table A.13: Hunter GP Access costs .................................................. 57 Table A.14: After hours home and ACF visits cost by State and
Territory ....................................................................................... 58 Table A.15: Total per patient cost of After hours home and ACF visits ..... 58
Analysis of after hours primary care pathways
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Table B.1: Financial cost of emergency department outcomes by
triage and age cohort ..................................................................... 61 Table B.2: Proportion of patients admitted and transferred by triage
category and cohort ....................................................................... 61 Table B.3: Per patient cost by cohort ................................................. 64 Table B.4: Per patient cost by cohort ................................................. 66 Table B.5: Comparison of patient pathway costs that include and
exclude admitted patient costs ......................................................... 66
Figures
Figure 2.1: After hours primary care operation times ........................... 18 Figure 2.2: After hours primary care policy and services timeline ........... 19 Figure 3.1: Patient pathway connections ............................................ 33 Figure A.1: Ambulance pathway ....................................................... 45 Figure A.2: Ambulance transports by jurisdiction ................................. 46 Figure A.3: Per patient cost of after hours and extended hours clinics ..... 52 Figure A.4: Healthdirect Helpline pathway .......................................... 54 Figure A.5: Hunter GP Access pathway .............................................. 56 Figure B.1: Emergency department triage category 4 presentation
cost ............................................................................................. 62 Figure B.2: Emergency department triage category 5 presentation
cost ............................................................................................. 63 Figure B.3: Category 4 ambulance patients ........................................ 65 Figure B.4: Category 5 ambulance patients ........................................ 65
Analysis of after hours primary care pathways
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Glossary
ACF Aged Care Facility
ACT Australian Capital Territory
AH After Hours
AIHW Australian Institute of Health and Welfare
ATS Australian Triage Scale
CAGR Cumulative annual growth rate
COAG Council of Australian Governments
ED Emergency Department
GP General Practitioner
GPAH General Practice After Hours Program
IHPA Independent Hospital Pricing Authority
Low acuity Low urgency
MBS Medicare Benefits Schedule
NAMDS National Association for Medical Deputising Services
NSW New South Wales
NT Northern Territory
RACF Residential Aged Care Facility
PBO Parliamentary Budget Office
QLD Queensland
SA South Australia
TAS Tasmania
UDG Urgency Disposition Groups
VIC Victoria
WA Western Australia
Analysis of after hours primary care pathways
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Key observations
Access to after hours primary care improved following a series
of government initiatives, particularly since 2005
– Improving access to primary care after hours has been a particular
policy objective for government, reflecting the changing preferences
of society and avoiding primary care being provided unnecessarily in
emergency departments as a last resort.
– Access to after hours primary care has increased significantly since
the Commonwealth Government introduced a series of policies in
2005 most significantly “Round the Clock Medicare: Investing in
After-Hours General Practice (GP) services”.
– These policies were introduced in response to declining after hours
primary care access as well as changing community preferences.
After hours pathways have different roles and ensuring the most
appropriate pathway is utilised has significant benefit to the
health system
– The lowest cost pathways for patients seeking after hours primary
care are extended and ‘after hours only’ clinics ($93) and after
hours home and Aged Care Facility (ACF) visits ($128). Emergency
departments is the most expensive at $1,351 if arriving by
ambulance (or treated and not transported) and $368 if self-
presenting.
– In 2012-13 AIHW estimated that 2.12 million presentations to
emergency departments were avoidable, GP-type presentations, of
which 63% occur after hours. If this quantum of presentations
occurred today, the cost would be approximately $0.8 billion. If a
quarter of the AIHW estimated number of the GP-type presentations
were diverted to either extended and ‘after hours only’ clinics or
home and ACF visits, the net benefit to the health system would be
$81.8 million to $93.5 million nationally.
– Further, a study of 50,000 patients who utilised home and ACF visits
showed that 94% would seek care using an alternative pathway if
the service did not exist. Based on the preference information, the
cost to the health system would be $181 million higher compared
with after hours home and ACF visits. Over four years, this would be
in the order of $724 million assuming no change in policy or
volumes.
A case study examined the availability of after hours home and
ACF visits and low acuity presentations to emergency
departments
– It is acknowledged that the differences in patient preferences in
accessing care pathways is complex and is influenced by a range of
different factors. In order to understand this relationship an analysis
of two discrete regions with similar population characteristics but
with markedly different access to after hours home and ACF visits
was undertaken.
– A case study considered rates of primary care and low acuity
emergency department presentations in two regions with similar
demographics: the Central Coast and the Gold Coast.
Analysis of after hours primary care pathways
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– The Central Coast had a lower utilisation of home and ACF visits,
and extended and ‘after hours only’ clinics and higher rates of low
acuity emergency department presentations compared with the Gold
Coast.
– Overall, the case study shows for two similar regions, Central Coast
has lower rates of after-hours home and clinic visits and higher rates
of low acuity emergency department presentations than Gold Coast.
Low acuity presentations as a proportion of total emergency
department presentations have declined since 2005-06, but
there are still a large number, particularly those arriving by
ambulance
– Lower acuity (category 4 and 5) presentations as a proportion of
total emergency department activity have declined from 54% to
47% over the period 2005-06 to 2014-15. Since 2011-12, more
urgent (category 1 to 3) presentations to emergency departments
have grown at higher rate at 7.0% than lower acuity (categories 4-
5) at 3.4%.
– Low acuity presentations arriving from ambulances have also
declined but still represent over 564,000 presentations or 23.7% of
total ambulance arrivals. Ambulance is the most expensive patient
pathway costing $1,351 per patient, which includes the cost of those
patients treated and not transported to an emergency department.
Ensuring access and choice should continue to be a government
policy objective
– Primary care is considered the cornerstone of the Australian health
system and access is crucial for delivering better quality and lower
cost outcomes.
– While access has improved, more can be done to further strengthen
access to after hours primary care. Particular for priority groups
including families, residents of in ACFs and those living with
disability.
– Trends in the delivery of health care centre on patient choice and
integrated care that includes treatment in the community as
opposed to hospital. Ensuring patients have choice in the service
and when it can be utilised based on their personal and clinical
circumstances is a policy priority.
– Community awareness of the availability of after hours services,
such as home and ACF visits, is low and could be improved to
improve the use of the most appropriate pathways.
Gold Coast Central Coast
Home and ACF visits /
1,000 people 82 2
Low acuity ED
presentations / 1,000
people
19 52
Analysis of after hours primary care pathways
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Executive summary
Primary care is an important part of Australia’s health system as it is often
the first point of contact for patients seeking care and a referral point to
other services. Evidence has shown that health care systems with strong
primary care produce better health outcomes for patients at a lower cost to
the health system.1 Given this, it is important that sufficient access exists to
promote equitable, appropriate and cost-effective treatment at all hours of
the day.
Improving access to after hours primary care is an important policy
objective for government
Improving access to primary care after hours has been a particular policy
objective for government, reflecting the changing preferences of society
changes in the GP workforce, community expectations and avoiding primary
care being provided unnecessarily in emergency departments as a last
resort.
The Commonwealth Government, which has responsibility for primary care,
introduced policy initiatives and services aimed at increasing access to
primary care in the after hours. The primary objective of the policy was to
increase access to primary care after hours in the face of declining
participation rates by General Practitioners (GPs) in providing after hours
care. The decline in home and Aged Care Facility (ACF)-visiting rates since
the 1990s resulted in patients seeking primary care from alternative
providers. This has meant that access to primary care for patients requiring
care in their own home (the elderly, disabled etc.) or for residents of aged
care facilities had significantly reduced.
The most significant reforms to address this decline in after hours primary
care was in 2005 when the Commonwealth Government introduced its
“Round the Clock Medicare: Investing in After-Hours GP services”, which
increased the Medicare Benefits Schedule (MBS) rebate for after hours
services including home and ACF visit items. Several subsequent MBS
initiatives built on this foundation. This policy focus has been further
supported through the introduction of new services such as Healthdirect
(nurse helpline) in 2006 and a range of State and Territory Government
initiatives designed to improve access to after hours primary care and
reduce primary care type presentations at emergency departments.
There were a number of reasons the Commonwealth Government improved
incentives for GPs to provide more after hours primary care. Improving
continuity of care for patients via increasing access to appropriate care
pathways, as an alternative to accessing emergency departments, was a
key driver for the policy.
There has also been changes in the demographics of the patients and GPs
that influence the demand and supply for primary care. More broadly,
consumers are seeking increased availability in how they access goods and
services in the economy. With increases in workforce participation rates,
1 World Health Organisation (2008), The World Health Report 2008: Primary health
care
Analysis of after hours primary care pathways
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particularly by females, services including primary care are required outside
of the traditional 9am to 5pm business hours. After hours primary care
assists in providing availability in accessing services that more adequately
meet changing work schedules and other family responsibilities.
For GPs, there has been a shift in the number of clinicians, the number of
hours being worked each week and a marked shift in their preference for
working predictable and less hours. Younger doctors have expressed a
preference to work in metropolitan settings to suit lifestyle choices and are
less likely to provide services in regional and rural areas. Research also
shows that financial incentives are not sufficient for regular GPs to provide
additional after hours coverage.2 The impact of these factors was a
reduction in participation by regular GPs delivering after hours primary
care.
Access and utilisation of after hours primary care has increased and
comprises a small amount of total expenditure
Commonwealth Government policy to improve access to primary care has
resulted in an increase in after hours primary care services being delivered.
The Parliamentary Budget Office estimated that more than 75% of growth
in MBS expenditure, including after hours items, was due to policy changes
that either increased the scope of services or increased the rebate.3 Chart i:
shows that since the introduction of the “Round the Clock Medicare:
Investing in after-hours GP services” and proceeding policy there has been
an 11.9% per annum increase in after hours MBS expenditure while in
hours expenditure has increased by 4.4% per annum over the same period.
Despite the higher growth rate, in hours MBS expenditure comprises 86.6%
of expenditure while out of hours comprises 13.4% per annum.
2 Melbourne Institute (2016), Do Financial Incentives Influence GPs’ Decisions to Do
After-Hours Work? A Discrete Choice Labour Supply Model
3 Parliamentary Budget Office (2015), Medicare Benefits Schedule – Spending trends
and projections (Report no. 04/2015)
Analysis of after hours primary care pathways
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Chart i: Change in and after hours MBS expenditure
Source: MBS
The fastest growing area of expenditure has been home and ACF visits
(14.6% per annum), comprising 5.5% of total expenditure. Over the same
period, there has been a decrease in the proportion of low acuity
presentations at emergency departments in Australia. Chart ii: shows the
change in mix of presentations between 2005-06 and 2014-15. The
proportion of category 4 and 5 presentations decreased from 54% to 47%
of total presentations.
$2.0b
$2.5b
$3.0b
$3.5b
$4.0b
$4.5b
$5.0b
$5.5b
$6.0b
2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
GP consults In hours home visits After hours clinics After hours home visits
11.9% growth p.a.
in after hours MBS
expenditure
4.4% growth p.a.
of in hours MBS
expenditure
Analysis of after hours primary care pathways
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Chart ii: Proportion of emergency department presentations by triage category
(2005-06 to 2014-15)
Source: AIHW (2015), Emergency department care 2014-15: Australian hospital statistics
The relative decline in category 4 and 5 presentations (low acuity
presentations) relates to a complex interaction of a number of factors that
influence the volume and mix of presentations, including access to
alternative care options, demographics and the triaging processes of
emergency departments.
1% 1% 1%
15% 18% 20%
29%31%
31%
43%41% 38%
11% 9% 9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2005/06 2011/12 2014/15
Category 1 Category 2 Category 3 Category 4 Category 5
Cat. 4 and 5: 54% Cat. 4 and 5: 50% Cat. 4 and 5: 47%
Case study – after hours home and ACF visits and emergency department presentations
The Commonwealth Government’s policy objective to expand access to after hours primary care, including
home and ACF visits, was to facilitate care in more appropriate settings and divert primary care type activity
from more expensive emergency departments that are established to provide emergency care. While the
differences in patient preferences in access care pathways is complex and is influenced by a range of different
factors, in order to understand the relationship an analysis of two discrete regions with similar population
characteristics but with markedly different access to after hours after hours home and ACF visits has been
undertaken.
A comparison was conducted of the per capita rate of after hours home and ACF visits and low acuity
emergency department presentations for two geographic areas with similar population characteristics: Central
Coast, NSW versus Gold Coast, Queensland:
Both areas are of a similar size in terms of population, have similar demographic characteristics and cover
a similar sized geographic catchment
Both regions have similar access to general practice services, with GP consultations at 1,348 per 1,000
people in Central Coast and 1,370 per 1000 in the Gold Coast (July to September 2015)
However both regions have different profiles in terms of accessing after-hours home and clinic visits, and
low acuity emergency department presentations
Central Coast has significantly lower rates of after hours home and ACF visits (2 per 1,000) and clinic visits
(67 per 1,000) than Gold Coast (at 82 home and ACF visits per 1,000; and 104 clinic visits per 1,000)
Central Coast has higher rates of low acuity ED presentations than Gold Coast at 52 per 1,000; compared
with 19 per 1,000 at Gold Coast
Analysis of after hours primary care pathways
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After hours pathways have different purposes and ensuring patients
access the most appropriate pathway has significant value to the
health system
There is a range of options available to the community to access primary
care after hours. However, access to these pathways is dependent on the
location, availability of services and circumstances of the individual.
Pathways such as emergency departments and ambulance services are
primarily designed to facilitate access to emergency care and to be able to
deal with the full range of medical responses that may be required. It is
recognised that ambulance and emergency department pathways are not
appropriate for primary care but act as an important option of last resort
when access to other options is poor. Other pathways such as GP clinics are
designed to deal with episodes that require attention or advice, but also
prevention, dealing with regular healthcare matters and early intervention
of deteriorating health conditions.
This report has considered the cost of each of these pathways through a
framework by considering the financial cost to the health system of a
patient requiring urgent primary care after hours. By definition, these costs
are borne by the Commonwealth Government, State and Territory
Governments and the individual (where gap payments or an ambulance
service may be involved).
The analysis shows that the highest cost patient pathways for after hours
primary care are emergency department via an ambulance ($1,351) and
emergency departments (self-referred) ($368). The lowest cost patient
pathway was extended and after hours only clinics ($93). The pathway with
the second lowest cost is after hours home and ACF visits ($128) where
urgent primary care is delivered in the individual’s place of residence (e.g.
home or ACF).
Table i: After hours primary care cost by patient pathway (per patient)
Pathway Weighted average patient
pathway cost
Emergency department (self-referred) $368
Ambulance to emergency department $1,351
Extended and after hours only clinics $93
Healthdirect $256
Hunter GP Access Scheme $169
After hours home and ACF visits $128
The benefits of providing awareness of and access to different pathways is
that it offers options for patients to receive care in the most appropriate
Daytime presentation rates to GPs were virtually identical across the two areas at 1,348 in Central Coast
and 1,370 for the Gold Coast
Overall, the case study shows for two similar regions, Central Coast has lower rates of after-hours home and
clinic visits and higher rates of low acuity emergency department presentations than Gold Coast.
Analysis of after hours primary care pathways
xiii
setting for their personal and clinical circumstance. Table i: shows the
differences in the cost per patient of each pathway is significant and where
access is poor, ambulance and emergency department pathways, which are
highest cost, become the pathways of last resort.
The difference in cost to the health system of utilising one pathway over
another is significant. For example, in 2015-16 there were 2.8 million home
and ACF visits item numbers. A survey of 50,000 (non ACF) patients who
accessed home and ACF visits revealed what alternative pathway would
have been accessed if they did not utilise after hours home and ACF visits,
as seen in Table ii:. The results of the survey show that the majority of
patients would have delayed seeking care or gone to a hospital emergency
department. The cost of each of these pathways has been quantified in this
report and used here to determine the cost per patient that would have
been incurred if they did not receive a home or ACF visit through after
hours home and ACF visits. It should be noted that patients in ACFs cannot
be surveyed and are therefore not included in the survey results. Residents
in ACFs requiring primary care in the after hours are likely to utilise an
ambulance, which is the most expensive alternative pathway. Including
residents of ACFs in the survey would increase the total cost per patient in
Table ii:.
Table ii: Cost per patient of accessing alternative pathways
Alternative Proportion of
patients Cost
Called an ambulance 4% $1,351
Gone to the hospital emergency department 27% $368
Gone to an after or extended hours clinic 18% $93
Delayed seeking medical care 44% $47
Gone without medical care 6% Not costed
Total 100% $192
Source: NAMDS Patient Survey, 2016
The weighted average cost of alternative after hours care is $192 per
patient. This is $64 per patient higher than the MDS ($128 in Table i:).
Over 2.8 million home or ACF visits item numbers occurred in 2015-16,
meaning that the total estimated additional cost to the health system of
accessing alternative pathways based on preferences surveyed was $181
million. Over four years, this would be in the order of $724 million assuming
no change in policy or volumes. This estimate is relatively conservative as
it:
Does not include the cost of potential higher downstream care
associated with patients delaying access to care, particularly for those
groups that have trouble accessing primary care due to personal
circumstances (e.g. disabilities, family responsibilities)
Only pertains to patients in a home environment (who can elect other
options); if ACF residents were included then the total estimated cost to
the health system would be higher as, in the absence of a ACF visit,
Analysis of after hours primary care pathways
xiv
operators of aged care facilities have no alternative than to arrange an
ambulance carry for a sick resident.
The majority of these costs are borne by governments; however, there are
increased out of pocket expenses for patients, particularly where ambulance
services, extended and after hours only clinics and in hours GP clinics with a
co-payment are used. In total, the Commonwealth Government would incur
less cost if after hours home and ACF visits did not exist, reflecting that
after hours home and ACF visits items are funded by the Commonwealth
and the alternative pathways are funded between a combination of
State/Territory Government and patients. The State and Territory
Governments would incur more cost. This is primarily driven by patients
attending emergency departments and utilising ambulance services instead,
which are predominately funded by State/Territory Governments. Finally,
patients would also incur more cost through utilising other GP services
(either in or after hours) that do not always bulk bill and ambulance
services where most jurisdictions charge patients a portion of the total cost.
This is summarised in Table iii:.
Table iii: Impact of removing after hours home and ACF visits by jurisdiction
State / Territory Commonwealth State/Territory Patient Total
NSW -$58.5m $108.6m $17.2m $67.3m
VIC -$59.9m $102.3m $21.2m $63.6m
QLD -$73.1m $92.4m $5.6m $24.9m
WA -$36.2m $43.8m $7.4m $15.0m
SA -$21.2m $22.7m $4.7m $6.1m
TAS -$3.5m $4.6m $0.4m $1.4m
ACT -$2.9m $3.3m $0.5m $0.8m
NT -$0.9m $2.2m $0.4m $1.8m
Australia -$256.2m $379.8m $57.4m $181.0m
The AIHW estimated that in 2012-13 there were 2.12 million presentations
in emergency departments categorised as avoidable GP-type presentations.
1.3 million (63%) of these presentations occurred in the after hours period,
as defined in section 2.1. The estimated direct financial cost of this activity
was $0.8 billion, not including the related costs associated with ambulance
transport. It is important to acknowledge that there is no consistent and
agreed definition of GP-type presentations in emergency departments and
estimating the number of these patients is problematic due to definitional
and data limitations. However, if a quarter of the AIHW’s estimated number
of avoidable GP-type patients avoided the emergency department through
improved access to extended or after hours clinics or the after hours home
and ACF visits the benefit to the health system would be $81.8 to $93.5
million nationally relating to emergency department costs.
Some groups have trouble accessing after hours primary care due to
their personal circumstances
Presently, one of the most frequent users of after hours primary care are
parents seeking assistance with children under the age of five years
demonstrating the demand for advice and care during after hours periods.
Families with multiple children and structured working requirements report
Analysis of after hours primary care pathways
xv
difficulties in seeking care during in hours periods.4 Access to home and ACF
visits facilitates access for these patients and prevents patients delaying or
avoiding care and potentially experiencing deteriorating conditions.
People living with disabilities and residents of ACFs also report difficulties in
accessing primary care. Approximately 800,000 people in 2012 were living
with a disability and needed to see a GP but did not as either the waiting
time was too long or services were not available when required.5 These
patients often require the assistance of a carer, which can have a significant
impact on the welfare of the carer, particularly during after hours periods.
Elderly patients living in ACFs are often transported to hospital by
ambulance because they are unable to obtain care at their place of
residence, particularly with the decline of home and ACF visits and access to
care in the after hours that has occurred between the 1994 and 2010
(noting that 1994 was the earliest data recorded). Ambulance transport is
the most expensive patient pathway at $1,351 per patient. Being able to
treat these patients at the ACF would reduce cost per patient to $128 if an
after hours home or ACF visit were utilised and avoiding an emergency
department presentation arriving via ambulance.
Providing choice ensures there is equitable access to primary care
in the after hours
Policy should continue to support choices that promote awareness and
access for patients to be treated in the most clinically appropriate settings.
This analysis shows that there are significant differences in the cost of the
various pathways; and where there is poor access to after hours clinics and
in home primary care services, the cost to the system is greater where
those patients present to emergency departments.
In addition to the clear differences in financial cost of each pathway, there
are additional benefits to patients, particularly the elderly, families with
young children and those living with disabilities and other individuals and
groups who would have difficulty leaving their homes. Improving access to
after hours primary care avoids health issues escalating and higher
downstream costs.
The cost differences highlight that for patients requiring urgent after hours
care, the lowest cost pathways are extended and after hours only clinics,
and home and ACF visits. The cost of treating these patients would be much
greater utilising emergency department and ambulance pathways. This
demand can also be an inappropriate use of critical resources for services
that are primarily designed to deal with emergency conditions.
In addition, key trends in health care centre on patient choice and
integrated care that includes treatment out of hospital and in the
community. Providing consumers with awareness, education and choice in
how to access appropriate care has clear benefits for the patient and the
system. There are also clear benefits for providing access to vulnerable
groups who have difficulties accessing care after hours without the use of
an ambulance such as elderly patients living in the community and
residents in residential aged care facilities.
4 Comino EJ, Zwar NA, Hermiz O. (2007). The Macarthur GP After-hours Service: a
model of after-hours care for Australia
5 AIHW (2012), Access to health services by Australians with disability 2012
16
1 Introduction
The National Association for Medical Deputising Services (NAMDS) has
engaged Deloitte Access Economics to assess the benefits of after hours
primary care pathways.6 NAMDS members deliver approximately 65% of
the after hours home and ACF visits in Australia. The remainder is served
by other after hours providers who are not part of NAMDS and those GPs
who still do some home visits.
There has been significant growth in the number of Australians accessing
after hours primary care over the last decade. Recent growth has been
because of a number of changes occurring in government policy, which has
expanded the access to and range of services available to the community
following broader trends in the health industry. These trends have included
factors that influence demand such as increased workforce participation
rates, which has led to people seeking more after hours primary care, and a
reduction in the number of doctors working hours during regular clinic hours
due to preferences of the GP workforce.
For GPs, there has been a shift in the number of clinicians, the number of
hours being worked each week and a marked shift in their preference for
working predictable and even less hours. These changes mean that there
are fewer hours being provided by GPs on average and therefore reduced
access for patients. There are also trends among younger doctors who
prefer to work in metropolitan settings to suit lifestyle choices and are less
likely to provide services in regional and rural areas. Research shows that
regular GPs have a growing preference for working in hours and that
financial incentives do not provide a significant enough incentive for them
to provide additional after hours coverage.7 The impact of these factors on
provision of after hours services was a marked reduction in participation by
regular GPs at the same time that patients were seeking care.
The increase in demand for after-hours services has attracted attention
from government who has sought to evaluate the most appropriate way to
deliver and fund after hours primary care in Australia, including the most
recent Review of after hours primary health care completed in October
2014.8 These reviews have identified that primary care is at the core of the
Australian health care system, and important for reducing downstream
demand and continuity of care for patients. There are still challenges in
accessing primary care for some patient groups due to their personal
circumstances.
The purpose of this report is to consider the primary drivers for the increase
in the number of people accessing after hours care, the benefits of after
hours pathways and the policy implications of further integrating after hours
primary care into the Australian health system.
6 A list of NAMDS members can be found at Appendix C
7 Melbourne Institute (2016), Do Financial Incentives Influence GPs’ Decisions to Do
After-Hours Work? A Discrete Choice Labour Supply Model
8 Jackson (2014), Review of after hours primary health care for the Department of
Health
17
2 After hours primary care in Australia
As a precursor to the analysis, this chapter provides context to the need
and role of after hours primary care in the health system, the current policy
context and factors that have influenced its supply and demand.
2.1 After hours primary care
Primary care is often the first interaction people have with the healthcare
system and is responsible for addressing healthcare needs and directing
them to other services as appropriate. The majority of primary health care
services are delivered through general practitioners (GPs) although other
professions such as nurses, dentists and mental health specialists deliver
additional services.
After hours primary care refers to periods during the week and on the
weekend (including public holidays) when GP clinics are typically closed.
After hours care (including transitional hours) is defined as the hours
between:
6pm to 6am Monday to Friday
12pm Saturday to 6am on Monday
All hours on public holidays.
It is noted that the definition of the after hours period is different depending
on the purpose. For instance, the after hours period defined in the MBS for
urgent after hours home visits (item numbers 597 and 599) do not include
all hours and typically include hours between 6pm to 11pm but not 11pm to
7am, which is covered through a separate MBS item number (599).9
Figure 2.1: shows that after hours care covers the majority of each day (14
hours on a working day), which results in 68% of all hours of a financial
year being defined as ‘after hours’.10
9 Item numbers 597 and 599 include hours: 7am to 8am and 6pm to 11pm Monday
to Friday, 7am to 8am and 12pm to 11pm on Saturday and 7am to 11pm on Sunday.
10 68% reflects an average of the number hours defined as after hours in each
jurisdiction in Australia (i.e. reflects differences in public holidays between jurisdictions, using the 2016/17 financial year as a base.
18
Figure 2.1: After hours primary care operation times
Source: Department of Health
2.2 Access to primary care
Access to primary care after hours is an important component of the
Australian health system given the impact on patients, doctors and the
broader health system when access is constrained. The primary driver of
increasing access to after hours primary care is to ensure continuity of care
rests with the regular GP and to reduce the number of presentations to
emergency department for primary care type services during these periods,
which was considered a more expensive pathway for dealing with patients
seeking access to primary care.
These benefits have long been recognised by governments who have
increased access to after hours primary care through a series of initiatives
such as telephone triaging and funding for after hours services at existing
GP clinics and other policy changes.
The most significant change in government policy was in 2005 when the
Commonwealth Government introduced after hours care reform “Round the
Clock Medicare: Investing in After-Hours GP Services”. This initiative
included three new funding components designed to increase access to after
hours care: operating subsidies; start up grants; and supplementary grants.
This initiative also included a host of Medicare incentives available to GPs
who provide after hours services, including a $10 loading to Medicare
rebates for after hours GP attendances. The Commonwealth Government
Mon. Tues. Wed. Thurs. Fr i. Sat . Sun.
Public
holidays
12am
10pm
8pm
6pm
4pm
2pm
12pm
10am
8am
6am
4am
2am
12am
After hours care
comprises 14 hours of a
working day and includes
addit ional hours on
weekends and public
holidays.
In hours After hours
19
continued to build on this policy initiative in 2007 when it extended access
to the $10 loading to include the ‘transition’ hours between 6pm and 8pm.
In 2008, the General Practice After Hours Program (GPAH) replaced the
former After Hours Primary Medical Care and “Round the Clock Medicare:
Investing in After-Hours GP Services” programs. The GPAH Program aimed
to ensure that as many people as possible had access to quality after hours
GP care. It did this by providing grants to support the viability of existing
and new after hours GP services, as well as those normal hour GP services
wishing to extend their hours of operation into the after hours period. These
grants were in operation until Medicare Locals were given responsibility for
allocating funding of after hours primary care in 2013.
Figure 2.2: After hours primary care policy and services timeline
The result of these initiatives was a significant increase in access to after
hours primary care by providers as these initiatives were designed to
provide stronger incentives, particularly between 2013 and 2016. Chart 2.1
shows that since the introduction of the initial initiative “Round the Clock
Medicare: Investing in After-Hours GP Services” in 2005 there has been a
significant increase in access to after hours services and a commensurate
increase in MBS expenditure on after hours care in Australia. Expenditure
has grown at a cumulative annual growth rate (CAGR) of 11.9% since
2005/06 for after hours GP clinics and home and ACF visits, reflecting this
policy. Over the same period, in hours primary care increased at a rate of
4.4% (CAGR). Despite the higher growth rate, in hours MBS expenditure
comprised 86.6% of expenditure while out of hours covering 68% of the
hours of the year comprised 13.4% in 2015-16.
Round the Clock Medicare: Invest ing in After-Hours GP Services
The Commonwealth Government increased the MBS rebate for after hours
GP services
‘Transitional Hours’ introduced
Two new MBS items introduced for urgent attendances in transitional hours (6-8pm on weekdays & midday to 1pm
on Saturdays)
Medicare Locals
responsible for after hours
funding
2005
Medicare Locals disbanded and PIP
after hours incent ives int roduced
2015
Approved Medical Deputising Service (AMDS)
Expanded the number of doctors available to work in after hours deputising services. Part of a suite of
policies and programs to improve the adequacy and quality of Australia's health workforce
2000
Rebates increased by 50% for medical
deputising
GP Super Clinics int roduced
to increase access to after hours GPs
2010
Healthdirectestablished
20
Chart 2.1: MBS expenditure on after hours versus in hours primary care
Source: MBS
The main reason for this increase in expenditure has been changes to policy
and rebate increases which underpinned expansion in access for patients
seeking care. The Parliamentary Budget Office (PBO) completed an analysis
of MBS expenditure to determine the reasons why expenditure had
increased and to predict the quantum of future expenditure. The PBO
estimated that more than 75% of this growth was due to policy changes
that either increased the scope of services or increased the rebate.11
Although this only considers the relevant MBS expenditure on after hours
GP clinics and home and ACF visits, there has also been a growth in the
number of after hours presentations at emergency departments. Emergency
departments are a significant form of after hours care and policies like
“Round the Clock Medicare: Investing in After Hours GP Services” were
developed in part to avoid emergency departments’ presentations,
particularly for GP-type presentations. It should be noted that only some
presentations to emergency departments are categorised as primary care
type presentations
The intent of Government policies in relation to after hours primary care
was to increase access in the context of a number of changes occurring in
the population’s attitude towards accessing services including working
patterns, lifestyle and also those delivering primary care services in
Australia.
Further, without awareness of and access to alternative primary care,
people seeking care had limited options and often presented at their local
emergency department, waited until they could get an appointment with
their regular GP the following day or did not seek care at all. Many primary
care and primary care support services were introduced (such as
11 Parliamentary Budget Office (2015), Medicare Benefits Schedule – Spending trends
and projections (Report no. 04/2015)
$2.0b
$2.5b
$3.0b
$3.5b
$4.0b
$4.5b
$5.0b
$5.5b
$6.0b
2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
GP consults In hours home visits After hours clinics After hours home visits
11.9% growth p.a.
in after hours MBS
expenditure
4.4% growth p.a.
of in hours MBS
expenditure
21
Healthdirect) to reduce the number of patients calling ambulances and
presenting at emergency departments.
There are numerous factors impacting on patient use of after hours primary
care, ranging from supply factors (e.g. access (supply of) to GPs) and
demand factors (e.g. changing patient’s requirements).
Supply factors
The ability of people to access a service is a key consideration in
determining whether the service will be used which is a function of the
number of doctors available, including their geographical location.
Significant barriers to receiving treatment from GPs will reduce the amount
of primary care being received. There have been numerous Commonwealth
Government initiatives developed to address the supply shortfall. For
example, the AMDS program was introduced via government legislation in
1999 to address scarcity of supply in after hours. Also, after hours items on
the MBS are paid at a premium to a similar item access in hours to
incentivise doctors to provide after hours care.
Research shows that regular GPs have a growing preference for working in
hours and that financial incentives do not provide a significant enough
incentive for them to provide additional after hours coverage.12
Demographics and family circumstances play a much smaller role in a
doctor’s choice to provide after hours care relative to obtaining regular
working hours.13 For example, GPs in Tasmania have stated that there is a
lack of willingness to work during after hours, particularly in the unsociable
hours14 while younger doctors are often looking to maintain consistent
working hours during social hours.15 The impact of these preferences is
seen in the reduction in the average working hours of GPs, which is
estimated to have reduced 3.4 hours per week in the decade leading up to
2009.16
The decline in home and ACF-visiting rates since the 1990s has resulted in
patients looking for other alternatives when seeking primary care. Chart
2.2: shows the number of home and ACF visits since 1993-94 per 100,000
people (the first year data was available). The trough of home and ACF
visits was in 2008-09; 56% of the number of visits per 100,000 people seen
in 1993-94.17 Home and ACF visits have increased since and were 71% of
the number of visits per 100,000 people when compared with the peak in
1993-94. This means there was significantly less access available for
patients requiring care in their own home (the elderly, disabled etc.) or for
residents of aged care facilities.
12 Melbourne Institute (2016), Do Financial Incentives Influence GPs’ Decisions to Do
After-Hours Work? A Discrete Choice Labour Supply Model
13 Melbourne Institute (2016), Do Financial Incentives Influence GPs’ Decisions to Do
After-Hours Work? A Discrete Choice Labour Supply Model
14 PHN Tasmania (2015), After hours general practice forum
15 Deeble Institute (2015), Review of after-hours service models: Learnings for
regional, rural and remote communities
16 Ibid
17 The latest available data from Medicare data is 1993-94. It is likely the peak was
prior to 1993-94.
22
Chart 2.2: Home and ACF visits: in hours and after hours (per 100,000 people)
Source: MBS
There is also the indirect consequence of patients being unable to obtain
appointments with their GPs during in hours periods. In 2014-15, 22.2% of
patients with a preferred GP noted that they were unable to obtain an
appointment with their preferred GP on one or more occasions and 27.6%
of patients did not seek a GP or were delayed in accessing a GP when
needed.18 A recent study of accessing GPs for ill children showed that 22%
of parents could not get a same-day appointment. The parents then need to
consider other alternatives.
Demand factors
There are also changes relating to patient circumstances and preferences
that mean patients increasingly seek treatment in the after hours. One of
the most significant trends is the increasing female participation in the
workforce (which has increased overall participation) meaning it is more
difficult for a greater proportion of the population to obtain care during
working hours (i.e. in hours). Chart 2.3: shows that workforce participation
has increased 77.1% from 1980 and females now comprise 46.6% of the
workforce compared with 40.7% in 1980. In families where both parents
(or carers) are engaged in the workforce, it can be difficult to obtain care,
particularly for children when trying to manage other children and working
arrangements. Access to after hours care can provide significantly more
flexibility in managing these situations. There is also a shift in broader
consumer expectations regarding the availability of all services where
people are further seeking the ability and need to plan around work and
family responsibilities and access services later at night, on weekends and
on public holidays.
18 ABS (2015), 4839.0 - Patient Experiences in Australia: Summary of Findings,
2014-15
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
19
93
-94
19
94
-95
19
95
-96
19
96
-97
19
97
-98
19
98
-99
19
99
-00
20
00
-01
20
01
-02
20
02
-03
20
03
-04
20
04
-05
20
05
-06
20
06
-07
20
07
-08
20
08
-09
20
09
-10
20
10
-11
20
11
-12
20
12
-13
20
13
-14
20
14
-15
"In hours' After hours
23
Chart 2.3: Workforce participation: males and females 1990 to 2016
Source: ABS (2016), 6202.0 - Labour Force, Australia, Sep 2016
Another factor influencing demand is the general community’s awareness of
the services available. For example, data provided by NAMDS shows that
regions with greater levels of awareness of the home and ACF visiting
services have a greater use. Based on a survey completed by NAMDS,
(unprompted) awareness was 26% of the population in 2016. Regions with
greater awareness such as South Australia (highest per capita use of after
hours home and ACF visits) had the highest level of awareness (36% or
more than double the national average).
2.3 Delivery of after hours primary care
There are numerous services available to people seeking after hours
primary care, which are funded by a combination of the Commonwealth and
the State and Territory governments. These range from telephone triage
services used primarily to provide advice, right through to services designed
to deal with serious episodes such as emergency departments.
At a high-level, the delivery of after hours primary care comprises the
following six services:
Emergency departments
Ambulance (and subsequent emergency department treatment)
Extended and ‘after hours only’ (or ‘dedicated AH clinics’) clinics
Healthdirect - telephone triage service
GP access schemes such as the Hunter GP Access Scheme
Home and ACF visits
Each service is discussed in turn.
2.3.1 Emergency departments
Emergency departments (public) delivered 8.9 million presentations in
2014-15 with approximately 68% of presentations occurring after hours.
They provide care 24 hours a day and 7 days a week for patients who
require urgent medical and surgical care with access to a broad range of
2,000
4,000
6,000
8,000
10,000
12,000
14,000
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016
Males Females
24
ancillary services such as imaging and pathology. Emergency departments
are not designed to provide ongoing care, which is predominately the
purpose of a patient’s regular GP.
Patients who attend emergency departments are triaged into one of five
categories based on how urgently they require care:
ATS category 1 – Resuscitation: Immediate care is required
ATS category 2 – Emergency: Care is required within 10 minutes
ATS category 3 – Urgent: Care is required within 30 minutes
ATS category 4 – Semi-urgent: Care is required within 60 minutes
ATS category 5 – Non-urgent: Care is required within 120 minutes.
On average, 75% of patients are seen within the timeframes mandated by
the triage categories. Patients are typically either treated and not admitted,
treated and admitted into a hospital ward, or transferred to another facility.
Some patients will leave before receiving treatment.
The majority of patients who attend emergency departments are not
patients who require only primary care outside of a hospital. The AIHW
estimated in 2013 that there were 2.12 million GP-type (i.e. could be
treated by a GP) presentations or 32% of total presentations.19 The AIHW
has reported that there are limitations associated with this estimate given
the difficulties in estimating the number of avoidable GP-type patients
based on the available data.20 The AIWH definition focuses on patients who
are triaged as category 4 and 5, did not arrive by ambulance and are not
admitted (or transferred).
Public emergency departments are the responsibility of State and Territory
Governments and provided at no cost to those patients seeking care. The
exact total expenditure on emergency departments in Australia is not
reported; however, the Independent Hospital Pricing Authority (IHPA)
reported that of the hospitals that provided information there was $4.0
billion in emergency department expenditure in 2013-14.21
Emergency department presentations have increased 41% from 5.2 million
in 2005-06 to 8.3 million presentations in 2014-15, an overall CAGR of
5.3%. Growth has been strongest over this period in category 2 (8.9%
CAGR) and category 3 (6.0% CAGR) as seen in Chart 2.4:. These
presentations are not included in the definition of ‘avoidable GP-type
presentations’ as the AIHW definition only includes presentations which are
categorised as triage 4 and 5. These categories grew at a slower rate, 3%
for category 5 or 4% for category 4.
19 AIHW (2013), 2012-13 Australian Hospital Statistics: Emergency department care
20 AIHW (2015), 2014-15 Australian Hospital Statistics: Emergency department care
21 IHPA (2016), Australian Public Hospitals Cost Report 2013-2014 Round 18
25
Chart 2.4: Public hospital emergency department presentations in Australia by
triage category
Source: AIHW (2015), Emergency department care: Australian hospital statistics 2014-15
Since 2011-12, emergency department presentations have grown at 5.2%
per annum. This is primarily due to growth in categories 1 to 3, which have
grown at a CAGR of 7.0% (i.e. they have grown at a higher rate than the
same categories 1, 2 and 3 for the period from 2005-06 to 2010-11). At the
same time, growth in category 4 and 5 presentations have grown slower at
a rate of 3.4% (CAGR) (as compared to a CAGR of 3.9% for category 4 and
5 between 2005-06 to 2010-11).
This is shown in Chart 2.5: - category 4 and 5 reduce from being 54% of
the total number of presentations in 2005-06 and 50% in 2011-12, to 47%
in 2014-15.
5.2m5.6m
5.9m 6.1m6.4m
6.7m7.1m
7.3m7.8m
8.3m
0.0m
1.0m
2.0m
3.0m
4.0m
5.0m
6.0m
7.0m
8.0m
9.0m
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15
Category 1 Category 2 Category 3 Category 4 Category 5
26
Chart 2.5: Change in the proportion of emergency department presentations by
category
Source: AIHW (2005-2015), Emergency department care: Australian hospital statistics
It is noted that there are a number of factors that influence the number of
emergency department presentations at each category. These factors
include access to alternative pathways, the triaging practices of the hospital
and the age, demographic and health profiles of those who present.
2.3.2 Ambulance
Ambulance services provide emergency and non-emergency transport to
patients in the community and at hospital. Transport is provided in a range
of vehicles ranging from road vehicles to fixed and rotary-wing aircraft.
Ambulance services are primarily designed to facilitate access to emergency
departments for patients unable to undertake travel due to their condition.
Ambulance services also undertake non-emergency transports and treat
patients in the community on the spot without a subsequent carry (referred
to as a treat, do not transport).
State and Territory Governments are responsible for funding ambulance
services; however, ambulance services set a schedule of fees that are
charged to users of the service. In some jurisdictions, ambulance services
are funded predominately by Government; however, the majority of
jurisdictions have fees to recover costs from users. These fees are
sometimes paid for by private health insurers (for those with coverage), or
the Commonwealth Government for eligible patients (e.g. veterans).
The number of patients being treated by ambulance services has grown
31.6% since 2004-05 although it has remained relatively flat over the past
3 years, as seen in Chart 2.6:.
1% 1% 1%
15% 18% 20%
29%31%
31%
43%41% 38%
11% 9% 9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2005/06 2011/12 2014/15
Category 1 Category 2 Category 3 Category 4 Category 5
Cat. 4 and 5: 54% Cat. 4 and 5: 50% Cat. 4 and 5: 47%
27
Chart 2.6: Number of ambulance patients in Australia
Source: Productivity Commission (2016), Report on Government Services
The majority of ambulance transports end at emergency departments,
including a large number of patients triaged as categories 4 and 5 at the
emergency department. Since 2011-12, arrivals have increased 3.4% per
annum (CAGR). This growth is largely attributable to categories 1 to 3
growing at 3.4%, 7.1% and 4.0% (CAGR) respectively – all at or above the
overall annual growth rate. Categories 4 and 5 have grown at a slower rate
over the same period. Category 4 has increased at 0.2% while category 5
has declined at 3.5%.
Although growth has been lower in low acuity presentations, they comprise
a significant number of the total number of presentations arriving by
ambulance. In 2014-15 patients triaged as either category 4 or 5 were
23.7% of the total number of presentations arriving by ambulance or over
564,000 as seen in Chart 2.7:.
2.4m 2.6m 2.7m 2.7m
2.8m 2.9m
3.0m 3.2m 3.2m 3.2m
2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15
28
Chart 2.7: Patients arriving by ambulance to emergency departments by ATS
triage category (‘000s)
Source: AIHW (20011-2015), Emergency department care: Australian hospital statistics.
Note (1): The emergency department triage categories are different to ambulance triage
categories.
Note (2): The AIHW did not publish arrival mode by triage category prior to 2011-12.
2.3.3 Extended and ‘after hours only’ clinics
An extended hours clinic is a regular GP clinic that offers appointments in
after hours periods. ‘After hours only’ clinics are clinics which only operate
during a part of the after hours period, often as a cooperative arrangement
between general practices within a geographic area. These clinics typically
do not offer 24-hour access but will remain open until 10pm or midnight in
more populated areas and open for fewer hours in less populated areas.
Extended and ‘after hours only’ clinics provide access to patients seeking
care regardless of the acuity.
2.3.4 Healthdirect Australia
The Council of Australian Governments (COAG) established Healthdirect in
2006, comprising 24-hour nurse-based triage that provide health advice
and information and referral to other health services. Healthdirect has had
over 5 million calls since inception and approximately 1 million calls in
2014-15.
The Healthdirect nurse-triage was expanded in 2011 to include the After
Hours GP helpline during after hours periods to assist people when their
regular GPs are not available.22 The GP helpline is not available during all
‘after hours’ times and differs depending on whether a person is located in
or outside a major city. Access to the After Hours GP helpline was cut back
22 Hours of availability do not align entirely with the definition of ‘after hours’ and are
different depending on whether you are located in a major city. The exact availability is available from: http://www.healthdirect.gov.au/after-hours-gp-helpline.
42.4 45.1 44.6 46.8
355.6 390.3 411.0 436.5
882.2 925.9 947.1 991.0
528.0534.5 530.5
531.636.4
33.8 33.732.7
2011-12 2012-13 2013-14 2014-15
Cat. 1 Cat. 2 Cat 3. Cat 4. Cat 5.
564.3k or 23.7% of
arr ivals are Cat 4 or
Cat 5 in 2014-15
29
in June 2015 and is now limited to patients calling from outside of
metropolitan areas.
When calling the nurse helpline, which is available in and after hours, a
caller speaks with a nurse who will provide information and advice
regarding the amount of care the patient requires and whether they should
seek care (e.g. from a GP or go to the emergency department). Chart 2.8:
shows the recommendations and advice provided to patients, which are
predominately referred to a GP (31.1%), the After Hours GP helpline
(21.5%), emergency departments (17.0%) and self-care (16.2%). The
majority of the users are parents of young children, women and those living
in remote areas.23
Chart 2.8: Healthdirect nurse-triage call recommendations/advice
Source: Healthdirect Australia (2015), Annual Report, Business Highlights 2014-2015
For 21.5% of patients, the nurse will refer the patient to the Healthdirect
After Hours GP Helpline – a phone advice and triage service run by GPs. The
nurse will assign a level of urgency to the case and a doctor will call back in
15 minutes to an hour, depending on the level of urgency. The majority of
calls end in self-care and advice being provided to the patients (65%)
where the patient can complete care by themselves or with the assistance
of a GP the next day.
23 RACGP (2016), Who uses the ‘after hours GP helpline’? A profile of users of an
after-hours primary care helpline
31.1%
21.5%
17.0% 16.2%
7.6% 6.6%
See a doctor(ranges fromimmediatelyto within 72
hours)
Speak totelephone GP
Emergencydepartmentimmediately
Self care Activate TripleZero (000)
Other
30
Chart 2.9: Healthdirect after-hours GP helpline recommendations/advice
Source: Healthdirect Australia (2015), Annual Report, Business Highlights 2014-2015
The majority of the clinical issues relate to providing advice on medication,
changing bowel habits, rashes, and coughs for children and
nausea/vomiting.24
2.3.5 GP Access Schemes
There are a few GP access schemes in Australia that provide a range of
services in order to better deal with patients’ diverse needs. The service
delivery models can vary but generally comprise a series of services,
including:
A phone triage service
GP clinics
Transport services
Home and ACF visits.
One of the larger GP Access schemes in Australia is the Hunter GP Access
scheme. The Hunter GP Access scheme is based in the Hunter Valley of
NSW and comprises all four elements noted above. The model is funded
through then Medicare Local funding and now PHN funding and is
considered an innovative way to treat patients during after hours care as it
provides a full suite of services for urgent care requirements. In 2013-14,
the Hunter GP Access had 74,206 calls to its triage service and the majority
were directed to an after hours clinics (60.7%). Other patients were
referred onto other services previously discussed such as Healthdirect
(12.3%) and to emergency departments (11.7%). The Hunter GP Access
scheme also undertakes limited home and ACF visits and funds transports
for patients who cannot access the clinic. Home and ACF visits and funded
transport comprised an insignificant component of its services (a total of
230 home and ACF visits and funded transports in 2013-14); its main
activity is triaging phone calls and clinic appointments.
2.3.6 After Hours Home and ACF Visits
After hours home and ACF visits provide patients with access to after hours
primary care through visits to the patient at their location (at home or
24 Ibid
47.2%
17.0%
9.7% 9.2% 9.0% 7.8%
Self-careadvice and
see adoctor/health
provider
See a GPimmediately
See a GPimmediately
(no GPavailable - goto emergencydepartment)
Self care athome
Emergencydepartmentimmediately
Other
31
ACF), although clinic and telephone services are also utilised. The term
deputising refers to the service delivery model whereby access to a GP is
provided when the patient’s regular GP is not available due to the timing of
the episode. After hours home and ACF visits are not considered an
alternative to a patient’s regular GP during the in hours periods, but instead
a temporary substitute. After a patient has been seen, a clinical report is
provided back to the patient’s regular GP in order to facilitate continuity of
care. There are almost 2,000 doctors employed by after hours home and
ACF visit providers with over 4,000 contractual relationships between them
and general practices to facilitate such care.
There are characteristics that are unique to after hours home and ACF visits
that do not necessarily apply to other after hours primary care pathways.
For instance after hours home and ACF visits:
Must provide home and ACF visits and access in the ‘unsociable hours’
between 11pm and 7am on weekdays and also the majority of hours on
the weekend. In many cases after hours home and ACF visits represent
the only primary care option in the unsociable hours other than EDs.
After hours home and ACF visits can also only be provided to patients
where urgent care is required and initiated by, or on behalf of, the
patient. Regular appointments are not permitted.
After hours home and ACF visits have grown over the past decade,
predominately through expansion of service areas for after hours home and
ACF visits, although some triage and clinic appointments are undertaken.
This is estimated to be a small amount of the total services provided.
Demand management protocols
Whilst workforce participation trends and the 24/7 global nature of many enterprises drive the utilisation of
after-hour services, there are a number of industry-lead proposed protocols that can manage demand. During
November 2016, NAMDS agreed a suite of policy measures, some of which address demand management,
continuity and quality.
Some of the measures approved by NAMDS include:
An industry wide code of conduct covering guidelines for:
– Triage protocols for emergency conditions that will not warrant a home or ACF visit.
– Triage protocols for non-urgent and non-episodic referrals to the GP that will not warrant a home or
ACF visit
– Monthly monitoring of frequent users and follow-up steps with the patient’s regular GP
– Protocols to address inappropriate drug seeking behaviour
– Protocols to encourage patients without a regular GP to establish one
– Agreed language in awareness campaigns
– Protocols for informing patients when clinics are open in the after hours
A new guideline for clarification of the meaning of urgency
Training and assessment of Doctors in MBS rules and billing requirements
Establishment of appropriate Medicare peer groups for after hours
Standard protocols to improve continuity of care and clinical handover
Work-force supply arrangements to strengthen the available Doctor workforce for after hours and aged
care facilities.
A collaborative working party to examine ways to improve palliative care in the home arrangements in the
after hours
32
3 Patient Pathway Analysis
The purpose of this analysis is to understand the costs associated with each
pathway available to patients seeking after-hours care. Each pathway is
designed to play a different role by dealing with different kinds of patient
needs and are resourced accordingly, which is important context for
interpreting the quantum of the financial cost.
Pathways such as emergency departments and ambulance services are
primarily designed to facilitate access to emergency care and be able to
deal with the full range of episodes that occur. Other pathways such as GP
clinics are designed to deal with episodes that require attention or advice,
but also prevention, regular healthcare needs (e.g. prescription renewals)
and early intervention of deteriorating health conditions, but will refer,
where appropriate more complex or urgent cases to the emergency
department.
The role of primary health care is to be the first point of contact for patients
with a health concern and important for assisting patients to navigate the
health system in the most clinically appropriate way. Continuity of care
resting with the regular GP is a cornerstone of Australian health policy.
Ensuring that access to primary care exists is important because it assists
in patients being treated in the most clinically appropriate setting.
Appendices A and B provide the detailed costing methodology and data
used in this analysis.
3.1 Comparison context
The comparison undertaken sought to examine the options for dealing with
patients seeking after-hours primary care, specifically determining the costs
incurred per patient using each alternative pathway, as well as the
respective qualitative advantages and disadvantages to patients and the
wider health system.
The pathways analysed within this report were:
Emergency department (self-referred)
Ambulance (and subsequent treatment in ED)
Extended and after hours only clinics
Healthdirect
Hunter GP Access Scheme
After hours home and ACF visits
The analysis has also considered the flow on effects of the linkages between
each of the pathways. For example, a patient may be referred to the
emergency department from a GP. The cost of both occasions has been
quantified as part of this analysis. Figure 3.1: presents the linkages
between the pathways. As can be seen only the emergency department is
delivered as a ‘standalone’ service that does not often refer back to other
services.
33
Figure 3.1: Patient pathway connections
Additionally, where possible, analysis has been considered in the context of
four patient cohorts to understand the unique impact on each. The patient
cohorts are described in Table 3.1:.
After and extended
hours clinic
After hours home
and ACF visits
Ambulance
Emergency
Department
Hunter GP Access
(triage)
Hunter GP Access
(clinic)
Healthdirect
(triage)
Healthdirect (after
hours GP helpline)
34
Table 3.1: Patient cohorts considered in this analysis
Patient cohort Age group Description
Baby / small child Less than 5 years
old
Often small children whose parents and/or guardians
make decisions regarding the most appropriate care
pathway required
Typical adult Between 20 and 60
years old
Average adult that represents the majority of the
Australian population
Elderly person living
at home
Over 75 years old Elderly people living at home
These patients often require support to obtain care in
settings outside of home
Elderly person living
in a ACF
Over 75 years old Elderly people living in ACFs often require more care (e.g.
feeding, rehabilitation) than those living at home
These patients often require support to obtain care in
settings outside of their ACF
In comparing each pathway, the unique role each pathway plays in offering
services to specific patient groups should be considered. For example,
whilst accessing primary care at home may be the most appropriate service
for an elderly person living alone, they may not be able to access this care
and instead utilise an emergency department or ambulance.25
3.2 Financial evaluation
Each pathway above is compared against a similar framework: the cost of
each pathway for patients seeking after-hours primary care. That is,
patients who require urgent care – where care is required on a timely basis,
or a patient is unable to access a GP outside of their residence (e.g.
disability).
There are several complicating factors in determining which patients fall
into this category. For example, only considering lower acuity (category 4
or 5) patients presenting at emergency departments fails to take into
account the complexity of a patient with comorbidities, mental health
issues, substance abuse related issues, or reasons a patient may
deteriorate quickly and may therefore not be a primary care type patient.
There is no consistent data definition that identifies these patients uniformly
across all care pathways. However, the AIHW defines an emergency
department patient that could have been treated by a GP as a patient
triaged as a category 4 or 5 that did not arrive by ambulance, was not
admitted, and was not transferred to another hospital. The cost related to a
patient subsequently admitted is also included for the purposes of
illustration given the potential for improved primary care access
contribution to avoiding unnecessary admissions (no quantitative
assessment of the aggregate potential impact is included).
25 AIHW (2016), Ageing, available at <http://www.aihw.gov.au/ageing/>
35
The detailed technical methodology used to determine the outcomes of this
section can be seen in Appendices A and B.
3.3 Financial evaluation results
Table 3.2: summarises the total cost per patient of each of the pathways
compared in this analysis. This includes, where relevant, the cost to the
patient, the State and Territory Governments, and the Commonwealth
Government. As can be seen, regardless of whether the analysis includes
subsequently admitted patients or not, the ambulance pathway (which
includes the emergency department) is considerably more costly than the
other pathways ($1,351), followed by those who self-present to an
emergency department ($368).
Costing over $250 when either excluding ($256) or including ($293)
patients that are subsequently admitted, Healthdirect is the next most
expensive pathway. Given that Healthdirect is an information and triage
service the majority of the associated cost relates to its function referring
on to other health services. For patients that only require the nurse triage
service and no further care the cost is estimated at $45 per service,
however this is only the case for 16% of callers, signifying the fact that the
service has little impact in deferring patients from other services.
The Hunter GP Access Scheme, after hours home and ACF visits and
extended and after hours only clinics pathways are the most cost effective
of this analysis ($169, $128 and $93 respectively), this being
representative of the fact that these services primarily exist to provide the
actual primary care. Despite this, the Hunter GP Access Scheme still refers
38% of patients on to other health services, this, along with the initial
telephone triage cost, accounts for the difference between that and the
other two pathways. The primary reason after hours home and ACF visits is
more expensive than extended and after hours only clinics is that a
premium is paid to incentivise doctors and takes into account the additional
cost of a home or ACF visit (chaperones, vehicle expenses, patient reporting
etc.).
Table 3.2: Comparison of patient pathway costs that include and exclude
admitted patient costs
Pathway Weighted average patient
pathway cost, excluding ED
costs of admitted patients
Weighted average patient
pathway cost, including ED
costs of admitted patients
Emergency department $368 $458
Ambulance $1,351 $1,548
Extended and after hours only
Clinics $93 $97
Healthdirect $256 $293
Hunter GP Access Scheme $169 $215
After hours home and ACF visits $128 $128
The two most costly pathways (ambulance services and emergency
departments) are established to predominantly deal with emergency and
urgent incidents, and as such, they require more costly capital and
36
workforce resources than are typically needed to deliver general primary
care services. Where access to primary care alternatives is limited, these
become pathways of last resort. Providing access to primary care
alternatives allows patients to be treated in alternatives to these pathways,
which can be more clinically appropriate where the care need is not an
emergency, and at a lower cost to the health system.
Access to primary care service options has a significant cost impact on the
health system as the less costly primary care alternatives of extended and
after hours only clinics and After hours home and ACF visits are $93 and
$128 or 25% and 36% of the cost of emergency departments. The AIHW
estimated that in 2012-13 there were 2.12 million presentations in
emergency departments categorised as avoidable GP-type presentations.
1.3 million (63%) of these presentations occurred in the after hours period,
as defined in section 2.1. The estimated direct financial cost of this activity
was $0.8 billion, not including the related costs associated with ambulance
transport. It is important to acknowledge that there is no consistent and
agreed definition of GP-type presentations in ED and estimating the number
of these patients is problematic due to data limitations. However, if a
quarter of the AIHW’s estimated number of avoidable GP-type patients
avoided the emergency department through improved access to extended
or after hours clinics or the after hours home and ACF visit the benefit to
the health system would be $80.8 to $93.5 million nationally relating to
emergency department costs.
The benefit to the health system of utilising one pathway over another is
significant. For example, in 2015-16 there were 2.8 million home and ACF
visit item numbers. A survey of 50,000 patients who accessed home and
ACF visits revealed what alternative pathway would have been access if
they did not utilise after hours home and ACF visits, as seen in Table 3.3:.
The majority of patients would have delayed seeking care or gone to a
hospital emergency department. The cost of each of these pathways has
been quantified in this report and used here to determine the cost per
patient that would have been incurred if they did not receive a home or ACF
visit through after hours home and ACF visits.
Table 3.3: Cost per patient of accessing alternative pathways
Alternative Proportion of
patients Cost
Called an ambulance 4% $1,351
Gone to the hospital emergency department 27% $368
Gone to an after or extended hours clinic 18% $93
Delayed seeking medical care 44% $47
Gone without medical care 6% Not costed
Total 100% $192
Source: NAMDS
The weighted average cost of alternative after hours care is $192. This is
$64 per patient higher than the after hours home and ACF visits ($128 in
37
Table i:). Over 2.8 million home or ACF visit item numbers occurred in
2015-16, meaning that the total estimated additional cost to the health
system of accessing alternative pathways based on preferences surveyed
was $181.0 million. This estimate is conservative on two basis: first, it does
not include the costs of potential higher downstream care associated with
patients delaying access to care, particularly for those groups that have
trouble accessing primary care due to personal circumstances (e.g.
disabilities, family responsibilities). Second, this estimate only pertains to
patients in a home environment (who can elect other options); if ACF
residents were included then the total estimated cost to the health system
would be higher as, in the absence of a ACF visit, operators of aged care
facilities have no alternative than to arrange an ambulance carry for a sick
resident.
The majority of these costs are borne by governments; however there are
increased out of pocket expenses for patients, particularly where ambulance
services, extended and after hours only clinics and in hours GP clinics are
used. In total, government (State and Commonwealth) would incur an
additional $61.70 per patient (for MBS items, emergency department and
ambulance costs) while patients would be required to pay an additional
$5.30 (for gap and ambulance payments) per patient.
Case study – after hours home and ACF visits and emergency department presentations
The Commonwealth Government’s policy objective to expand access to after hours primary care, including
home and ACF visits, was to facilitate care in more appropriate settings and divert primary care type activity
from more expensive emergency departments that are established to provide emergency care. While the
differences in patient preferences in access care pathways is complex and is influenced by a range of different
factors, in order to understand the relationship an analysis of two discrete regions with similar population
characteristics but with markedly different access to after hours after hours home and ACF visits has been
undertaken.
A comparison was conducted of the per capita rate of after hours home and ACF visits and low acuity
emergency department presentations for two geographic areas with similar population characteristics; Central
Coast, NSW versus Gold Coast, Queensland:
Both areas are of a similar size in terms of population, have similar demographic characteristics and cover
a similar sized geographic catchment
Both regions have similar access to general practice services, with GP consultations at 1,348 per 1,000
people in Central Coast and 1,370 per 1000 in the Gold Coast (July to September 2015)
However both regions have different profiles in terms of accessing after-hours home and clinic visits, and
low acuity emergency department presentations
Central Coast has significantly lower rates of after hours home and ACF visits (2 per 1,000) and clinic visits
(67 per 1,000) than Gold Coast (at 82 home and ACF visits per 1,000; and 104 clinic visits per 1,000)
Central Coast has higher rates of low acuity ED presentations than Gold Coast at 52 per 1,000; compared
with 19 per 1,000 at Gold Coast
Daytime presentation rates to GPs were virtually identical across the two areas at 1,348 in Central Coast
and 1,370 for the Gold Coast
Overall, the case study shows for two similar regions, Central Coast has lower rates of after-hours home and
clinic visits and higher rates of low acuity emergency department presentations than Gold Coast.
3.4 Other impacts
In addition to the financial costs, there are wider system impacts, both
positive and negative, resulting from the use of each pathway. Although
each pathway serves a fundamental purpose there are negative outcomes
38
associated when they are used inappropriately, or as a replacement for a
more effective and efficient service already provided, such as an in hours
GPs, extended and after hours only clinics or after hours home and ACF
visits.
As previously mentioned, emergency departments and ambulance services
are last resort services to treat the most emergent and complex patients
that could otherwise not be treated in primary or community care settings.
When used to treat more primary care type patients these services become
strained, emergency departments become overcrowded and ambulance
services reach capacity, negatively impacting patient outcomes in several
ways, including:
Longer wait times
Increased hospital length of stay
Higher mortality rates
Poorer patient experience
As identified, Healthdirect is a highly expensive pathway when factoring in
the costs associated in referring patients to other services. In addition to
this, it can often end up being an unnecessary additional step in a patient
pathway. A Medical Journal of Australia study with the Royal Perth Hospital
indicated that fewer referrals from Healthdirect to the emergency
department were appropriate (72.9%) compared to self-referred patients
(73.7%). This highlights the fact that the additional extra step in the
patient pathway can add little value to the patient’s decision.
Extended and after hours only clinics provide an efficient and effective
pathway to those patients that can access them. They are often the most
appropriate place for primary care type patients to be treated after hours,
particularly for non-urgent requirements.
However, unlike after hours home and ACF visits, extended and after hours
only clinics provide limited alternatives to those patients that are unable to
access services outside of their place of residence and none at all during the
unsociable hours. There are a number of instances where patients may not
be able to access primary care, particularly in after hours periods:
Parents with young children: Families with multiple children and
structured working requirements report difficulties in seeking care
during in hours periods.26 Parents with young children are also one of
the most frequent users of after hours services.
People living with disabilities: People living with disabilities and at ACFs
also report difficulties in seeking primary care. Approximately 800,000
million people in 2012 were living with a disability and needed to see a
GP but did not go as either the waiting time was too long or services
were not available when required.27
Elderly patients living in ACFs: Elderly patients living in ACFs are often
transported to hospital by ambulance because they are unable to obtain
care at their place of residence, particularly with the decline of home
visits and access to care in the after hours. Ambulance transport is the
most expensive patient pathway at $1,351 per patient and can be
avoided in many cases if care is provided at the place of residence.
26 Comino EJ, Zwar NA, Hermiz O. (2007). The Macarthur GP After-hours Service: a
model of after-hours care for Australia
27 AIHW (2012), Access to health services by Australians with disability 2012
39
These scenarios highlight a role for increasing access to after hours primary
care, particularly for home visits through After hours home and ACF visits
where patients would otherwise access clinically less appropriate and more
costly services such as ambulances and emergency departments. Access to
home visits facilitates access to primary care for these patients and
prevents patients going without care and potentially deteriorating.
3.5 Summary
There are a number of alternatives for patients seeking after hours primary
care in Australia ranging from emergency departments to after hours clinics
and home visit services. Each of the patient pathways has a role in
delivering after hours primary care to the community and ultimately
patients should be treated in the most clinically appropriate setting where
access is available.
This analysis has considered the cost per patient of each pathway and
shows that the most costly pathways for treating a primary care patient are
the ambulance service ($1,351) and emergency department ($368). The
least costly pathways are extended and after hours only clinics ($93) and
after hours home and ACF visits ($128). Given the significant difference in
cost, there is a strong argument for patients requiring primary care to be
treated in after hours clinics or through after hours home and ACF visits.
There are significant differences in the cost of the various pathways and
where there is poor access to after hours clinics and in home primary care
services the cost to the system is greater where those patients emergency
departments either self-presenting or by ambulance for primary care type
attendances. In addition to the clear differences in financial cost of each
pathway, there are additional benefits to patients, particularly the elderly,
families with young children and those living with disabilities and other
individuals and groups who would have difficulty leaving their homes.
Improving access to after hours primary care avoids health issues
escalating and higher downstream costs.
40
Appendix A: Patient pathway analysis
The purpose of this analysis is to understand the costs associated with each
pathway available to patients seeking after hours care. Each pathway is
designed to play a different role by dealing with different kinds of patient
needs and are resourced accordingly, which is important context for
interpreting the quantum of the financial cost.
Pathways such as emergency departments and ambulance services are
primarily designed to facilitate access to emergency care and be able to
deal with the full range of episodes that occur. Other pathways such as GP
clinics are designed to deal with episodes that require attention or advice
but also prevention and early intervention of deteriorating health conditions
but will refer more complex or urgent cases to the emergency department.
The role of primary health is to be the first point of contact for patients with
a health concern and important for assisting patients to navigate the health
system in the most clinically appropriate way. Ensuring that access to
primary care exists is important as it assists patients in being treated in the
most appropriate setting, which is also often at a lower cost to the health
system.
A.1. Analytical framework
There are numerous pathways available to patients seeking after hours
primary care. The pathways considered in this analysis are:
1. Emergency departments
2. Ambulance service
3. After hours and extended hours GP clinics
4. Healthdirect
5. Hunter GP Access scheme
6. After hours
Each pathway above is being compared against a similar framework: the
cost of the pathway for patients seeking after hours care that could have
been treated by a GP. That is, patients who require urgent care – where
care is required in a timely basis or a patient has issues that prevent access
to a GP outside of their residence (e.g. disability).
The analysis is also being considered in the context of the outcomes for four
patient cohorts, as described in Table A.1:.
41
Table A.1: Descriptions of patient cohorts
Patient cohort Age group Description
Baby / small child Less than 5 years
old
Often small children whose parents and/or guardians
make decisions regarding the most appropriate care
pathway required
Typical adult Between 20 and 60
years old
Average adult that represents the majority of the
Australian population
Elderly person living
at home
Over 75 years old Elderly people living at home
These patients often require support to obtain care in
settings outside of home
Elderly person living
in a ACF
Over 75 years old Elderly people living in ACFs often require more care (e.g.
feeding, rehabilitation) than those living at home
These patients often require support to obtain care in
settings outside of their ACF
The significance of considering each alternative pathways by age cohort
primarily relates to the impact that seeking care in after hours has on other
people and services. For example, babies and small children are
accompanied by parents and/or guardians, which has impacts outside of
those on the health system and patient. Elderly patients living at home may
also require assistance from a family during an episode, particularly in
making decisions about the most appropriate care that may be required
during and post hospital.
Where possible, the costs and benefits of each cohort have been considered
separately; however, data were not available for some pathways and
cohorts. Where this is the case, the cost is considered as one that impacts
all age cohorts similarly.
A.2. Emergency department
The emergency department is a commonly used pathway for patients
seeking after hours care. An emergency department is considered one of
the most expensive pathways for treating lower acuity patients as they are
primarily designed and equipped to deal with life-threatening emergencies.
When a patient arrives at an emergency department, clinical staff triage the
patient and assign a triage category based on their assessment of the
patient’s condition; the triage score determines how quickly the patient
requires care. Australian emergency departments use the Australasian
Triage Scale (ATS), which consists of five categories:
ATS category 1 – Resuscitation: Immediate care is required
ATS category 2 – Emergency: Care is required within 10 minutes
ATS category 3 – Urgent: Care is required within 30 minutes
ATS category 4 – Semi-urgent: Care is required within 60 minutes
ATS category 5 – Non-urgent: Care is required within 120 minutes.
The focus of this analysis is to consider the outcomes of patients that
potentially could have sought after hours care from other pathways such as
42
GPs. Patients assigned an ATS category between 1 and 3 are likely to have
required care in the emergency department environment. Patients triaged
as either category 4 or 5 are lower acuity patients that may have been
more appropriately treated outside of the emergency department by a GP.
This is consistent with definitions used by the AIHW in determining the
number of low acuity and potentially preventable presentations at
emergency departments.28 The AIHW definition also includes other
parameters, namely the patient did not arrive by ambulance, was not
admitted or transferred to another hospital or died.
Therefore, for the first component of this analysis the patient-level
emergency department data containing the details of emergency
department presentations in Australia has been used to determine the
outcomes of patients that:
Self-present at emergency departments in after hours periods
Are triaged as category 4 or 5
Are not transferred.
The analysis presented below separately reports the cost of patients that
are admitted and not admitted. The AIHW definition excludes patients
admitted however, it is acknowledged that a proportion of admitted activity
is potentially avoidable where adequate access to primary care existed.
A.2.1. Financial cost
Applying the AIHW definition to emergency department presentations
means that the cost of a patient arriving at the emergency department is
equal to the cost of a non-admitted patient as classified by the Independent
Hospital Pricing Authority (IHPA).
The IHPA publishes a series of emergency department costs based on a
classification system known as Urgency Disposition Groups (UDG). UDGs
group patient presentations based on the type of visit, episode end status
and triage.29 These UDGs allow for an estimate of the cost of each triage
category to be determined for non-admitted patients. UDGs have been used
to determine the cost of patients presenting to emergency departments
who have been triaged as category 4 or 5. IHPA also provides costs by UDG
for three separate age cohorts:
Under 65 years old;
65 to 79 years old; and
Over 79 years old.
The cost associated with two of IHPA’s age cohorts have been utilised to
align to the patient cohorts being considered in this analysis:
The ‘Under 65 years old’ category has been applied to the baby / small
child and typical adult cohorts
The ‘Over 79 years old’ category has been applied to the remaining two
cohorts: elderly people living at home and in ACFs.
28 AIHW (2016), National Healthcare Agreement: PI 19–Selected potentially avoidable
GP-type presentations to emergency departments, 2016 29 IHPA (2016), Urgency Related Groups and Urgency Disposition Groups, available
at: https://www.ihpa.gov.au/what-we-do/urgency-related-groups-and-urgency-disposition-groups
43
The IHPA age cohorts do not align exactly with the description of the patient
cohorts in this analysis. However, they do provide data points that are more
relevant compared with an average cost across all age cohorts. Presented in
Table A.2: is the relevant UDG cost for triage categories 4 and 5 and patient
cohort.
Table A.2: Cost of emergency department presentations by triage category and
age cohort
Age cohort Category 4 Category 5
Under 65 years old $369 $240
Over 79 years old $447 $291
Source: Independent Hospital Pricing Authority (2016), Emergency Department costs
As would be expected, patients in the ‘Over 79 years old’ cohort cost 21%
more in category 4 and 5 than patients who present ‘Under 65 years old’.
This is because elderly patients are often more complex to treat than
younger patients as they are more likely to present with multiple conditions
and take a longer time to respond to treatment.
These costs have been applied in proportion to the number of emergency
department presentations occur for each patient cohort between category 4
and 5. Table A.3: shows the cost of the emergency patient pathway by
patient cohort. An elderly person living in an ACF is the highest cost of the
patient pathways. These patients require transport back to their ACF, which
often requires an ambulance transfer at a cost of $332. The difference
between the weighted average cost of $358 calculated in Table A.3: and the
$368 in Table A.3: is the higher cost of elderly patients living in ACFs as
they are assumed to transport back to the ACF – the $10 difference
represented the cost per patient on this transport.
Table A.3: Emergency department cost by patient cohort (non-admitted)
Patient cohort Cost Proportion
Baby / small child $359 23.0%
Typical adult $367 60.0%
Elderly person living at home $324 14.9%
Elderly person living in a ACF $804 2.0%
Weighted average (incl.
transports to ACFs) $368 100.0%
Note: The cost of the “Elderly, living in a ACF’ includes the cost of an ambulance transport back to
the ACF’
A.2.2. Other costs
Emergency departments also have a number of other costs aside from the
direct financial impact on hospital expenditure.
One of the main impacts is overcrowding in emergency departments –
where too many people present and are admitted, which compromises
44
access and care in the emergency department. There are a number of
sources of access block in emergency departments. One study showed that
patients who could have sought care from a GP and a lack of bed capacity
within inpatient wards were two main reasons for access block. It is
acknowledged that there are a complex set of factors that impact on access
block and overcrowding. Increasing access to alternative care pathways for
primary care type presentations is one of a number of strategies to improve
access to care for patients requiring emergency care.
As more people present and are admitted to the emergency department,
access to beds becomes limited and patients remain waiting. This has a
number of impacts, including:
More time spent waiting for care
Increased hospital length of stay
Higher mortality rates: A number of studies has shown that access block
in the emergency department, combined with a lack of capacity in
inpatient wards can increase mortality rates by 30%
Ambulance handover times and diversion: As emergency department
capacity becomes unavailable, ambulances must either spending longer
waiting to handover over patients or divert to another site. Both can
result in tying up ambulance resources.
A.3. Ambulance
Separate ambulance services operate in each jurisdiction and are funded
differently with a combination of user-pay fees and government funding.
This pathway considers the cost associated with triaging, responding and
treating patients.
A.3.1. Financial cost
As seen in Figure A.1: the cost of the ambulance pathway comprises the
cost incurred by:
Ambulance services: Transporting patients or providing care at the place
of the episode
Hospital emergency departments: Many requests for an ambulance end
in a patient being transported to an emergency department – the cost of
the patient being admitted, treated or transferred occurs because of the
ambulance arrival.
A.3.1.1. Ambulance services
This pathway starts at the point of an ambulance being requested and
therefore excludes any cost incurred before that point.
45
Figure A.1: Ambulance pathway
Ambulances transport the majority of patients. In 2015-16, the Productivity
Commission’s Report on Government Services reported that across
Australia 86.3% of patients receive either emergency or non-emergency
transport, as seen in Figure A.1: The proportion of patients requiring
transport varies across each jurisdiction.
Emergency transport
Non-emergency
transport
Treat No Transport
(TNT)
Transport to ED
Do not transport
Ambulance
Admit
Did not admit
Transfer
Emergency Dept.Ambulance
46
Figure A.2: Ambulance transports by jurisdiction
Source: Productivity Commission (2016), 2015-16 Report on Government Services
Understanding the number of patients transported is important as it
contributes to the overall cost to the ambulance service and determines
whether patients are transported to an emergency department. On
average, patients transported incur higher fees (and ambulance services
incur a higher cost) and are transported to the emergency department in
the majority of cases.
The exact cost of the various transport options is not publicly available;
however, all ambulance services publish a schedule of fees that the user of
the service is liable to pay.30 Table A.4: shows the scheduled fees by
jurisdiction. These fees have been used to indicate the cost incurred by the
ambulance service in delivering transport and non-transport services in the
ambulance pathway analysis.
30 The user of the service is different depending on the circumstances. These
arrangements vary by jurisdiction.
Emergency transport
Non-emergency
transport
Treat No Transport
(TNT)
Transport to ED
Do not transport
Ambulance
Admit
Did not admit
Transfer
Emergency Dept.Ambulance
86.3%
13.7%
Jurisdiction Transported to ED Do not transport
NSW 81.5% 18.5%
Vic 87.1% 12.9%
Qld 89.9% 10.1%
WA 87.7% 12.3%
SA 88.6% 11.4%
Tas 81.2% 18.8%
ACT 81.8% 18.2%
NT 79.0% 21.0%
Australia 86.3% 13.7%
47
Table A.4: Scheduled ambulance service fees
Jurisdiction Emergency Non-emergency Treat no transport
Fixed fee Variable Fixed fee Variable Fixed fee Variable
NSW $364 $3.3/km $287 $1.8/km - -
VIC $1,341 - $383 - $507 -
QLD $1,214 - $450 $1.9/km $124 $16.9/km
WA $932 - $500 - - -
SA $934 $5.4/km $208 $5.4/km $205 -
TAS $833 $5.6/km - $5.6/km $575 -
ACT $918 - $656 - $637 -
NT $745 $4.8/km $340 $4.8/km - -
Source: NSW: http://www.ambulance.nsw.gov.au/Accounts--Fees/Fees-and-Charges.html, Vic: https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/ambulance-and-
nept/ambulance-fees, Qld: https://www.legislation.qld.gov.au/LEGISLTN/CURRENT/A/AmbulServR15.pdf, WA:
http://www.stjohnambulance.com.au/ambulance-and-health-services/metro-ambulance-service/metro-ambulance-fees, SA: http://www.saambulance.com.au/ProductsServices/Ambulancefees.aspx, Tas:
http://www.gazette.tas.gov.au/editions/2014/april_2014/21422_-_Gazette_23_April_2014.pdf, ACT: http://esa.act.gov.au/actas/fees-and-charges/, NT: http://www.stjohnnt.org.au/ambulance-
services-introduction
These arrangements are different in each jurisdiction and depend on the
circumstances in which a patient requires assistance. For example, patients
in Queensland, Tasmania and the Northern Territory are not directly liable
for the cost of ambulance transports – the government in each jurisdiction
funds these services using general taxation revenues.
Additionally, each State and Territory Government makes significant
contributions to the cost of delivering ambulance services and the costs
recovered through the user-pays fees do not cover the entire cost. In 2014-
15, Government grants and contributions comprised 68% or $1.9 billion of
total ambulance revenue as seen in Chart A.1: – Government grants and
contributions are higher in jurisdictions where the general community is not
often liable for the cost of ambulance transport.
48
Chart A.1: Proportion of Government grants and contributions to ambulance
revenue
Source: Productivity Commission (2016), Report on Government Services
Given this analysis focuses on the cost of each after hours care pathway,
the ambulance fees have been increased to reflect the component of the fee
that is being funded by Government through grants and contributions. This
results in the cost per patient in Table A.5: – non-emergency transport
costs on average $937 and treat no transport $897. The emergency fee has
been excluded from Table A.5: as it has been assumed that patients
requiring out of hours care from a GP would not require emergency
ambulance. The total weighted average cost per patient is $957.
Table A.5: Cost per patient – non-emergency and treat no transport
Proportion Cost
Non-emergency transport 86.3% $932
Treat no transport 13.7% $980
Weighted average cost 100% $957
A.3.1.2. Emergency departments
The cost of an emergency department presentation was calculated in
Section A at $358 per patient. This calculation was based on non-admitted
emergency department costs of patients self-presenting to emergency
departments, and the relative proportions of patients in each age cohort.
The cost of an emergency department relating to an ambulance arrival has
been calculated here using the same IHPA emergency department costs in
Table A.6: however; the proportion of each patient cohort has changed to
reflect the number of patients who arrive by ambulance. This has been
determined using the AIHW’s patient-level emergency department data and
is summarised in Table A.6: alongside the IHPA emergency department
costs.
85% 85%82%
79%
70%66%
52%48%
68%
NT ACT Tas Qld NSW Vic SA WA
49
Table A.6: Non-admitted patient costs by age cohort and triage category
(arrived by ambulance)
Age cohort Category 4 Category 5
Cost Proportion Cost Proportion
Under 65 years old $369 76.2% $240 24.2%
Over 79 years old $447 23.8% $291 75.8%
Weighted average
cost / Total $388 100.0% $279 100.0%
Source: IHPA, AIHW
Table A.7: presents the non-admitted patient costs of each triage category
and the total weighted average cost.
Table A.7: Total non-admitted patient costs (arrived by ambulance)
Triage category Cost Proportion
Category 4 $388 93.6%
Category 5 $279 6.4%
Weighted average cost $381 100.0%
Source: IHPA, AIHW
The proportions are different to the ones used to calculate the emergency
department cost of $358 – the proportion of patients to apply to the ‘Over
79 years old’ category is 10.2% higher, meaning that the higher cost for
elderly patients is likely to be incurred more often and the overall cost
increases by $23 to $381.
A.3.1.3. Summary: Ambulance and emergency department costs
The total cost of the ambulance service includes both the ambulance and
emergency department components calculated above. Table A.8: shows the
combined cost of the two components which equates to $1,338 per patient.
Table A.8: Weighted average cost of ambulance pathway
Triage category Cost
Ambulance $957
Emergency department $381
Weighted average cost $1,338
By patient cohort, the analysis shows the cost for elderly patients is
significantly higher than for the other two cohorts as seen in Table A.9:
50
Table A.9: Ambulance and emergency department per patient costs
Cohort ED Component Ambulance Component Total
Baby / small child $365 $957 $1,322
Typical adult $366 $957 $1,323
Elderly, living at home $419 $957 $1,376
Elderly, living in a ACF $819 $957 $1,776
Total / weighted average $394 $957 $1,351
Note: The ED component for ‘Elderly, living in a ACF’ include the cost of an ambulance transport
back to the ACF
The difference between $1,338 in Table A.8: and $1,351 in Table A.9: is
due to the cost of ACF patients requiring transport back from the
emergency department.
A.3.2. Other costs
Using ambulance services for low acuity patients ties up valuable resources.
Ambulance services are required to respond to incidents 24 hours a day and
7 days a week within a specified time based on the urgency of the situation.
Using ambulance resources on low acuity patients means that additional
resources are required to respond to any emergencies that may occur. This
can mean that ambulances require more resources and therefore cost – in
an absolute sense – significantly more.
As ambulances often take people to emergency departments the costs
associated with emergency departments noted above (e.g. access block and
the impact on carers) also applies in this pathway.
A.4. Extended and after hours only clinics
Extended and after hours only clinics provide typical GP services to patients
outside of normal operating hours. The key difference between the two
types of clinics is that after hours clinics specifically cater for after hours
periods while extended care clinics are regular GP clinics that remain open
into the after hours periods.
A.4.1. Financial costs
Patients presenting at an after hours or extended hours clinics are either:
Treated and released: patients that are treated and released from the
clinic; or
Hospital emergency departments: Those patients are assessed and then
referred to an emergency department – this cost has been factored in as
it is as a direct result of an after hours or extended hours clinics referral.
According to the Hunter Research Foundations Cost Study of GP Access
After Hours, 96% of extended and after hours only clinic appointments
result in a patient being treated and released from the clinic in that single
episode of care, whilst the other 4% are referred on to an emergency
department.
Determining these proportions enables us to calculate the per patient cost
of extended and after hours only clinics by factoring in the proportionate
51
cost of the emergency department. The cost of an emergency department
presentation has been quantified above in the emergency department
pathway ($368 per patient), and used in determining the total weighted
average cost of this pathway. The cost by patient cohort has not been
separated due to data limitations.
The average cost of extended and after hours only clinics appointments has
been calculated using 2015-16 activity and cost data for all relevant
Medicare Benefits Schedule items supplied. This included all commonly used
after-hours Medicare Benefit Schedule items for GPs, as can be seen in
Appendix C. In order to determine the gap payment of each clinic
appointment the bulk billed rate of each state provided by Medicare
Statistics has been used. Finally, the after-hours bulk billing incentive of
$6.2 was included after the gap payment as it is an incentive to bulk billing
appointments only. It should be noted that in certain rural locations the
incentive is $9.3 instead of $6.2. Table A.10: shows the total Medicare
expenditure, total activity, Medicare cost per appointment, and gap
payment.
Table A.10: Extended and after hours only clinics cost by State and Territory
Jurisdiction Total Medicare
expenditure ($)
Total activity Medicare cost per
appointment
Gap cost per
appointment ($)
NSW $151,013,934 2,885,762 $52.3 $13.6
VIC $155,235,763 2,947,695 $52.7 $27.3
QLD $72,876,451 1,369,176 $53.2 $13.8
WA $31,872,383 603,354 $52.8 $27.3
SA $27,633,526 520,812 $53.1 $14.6
TAS $3,081,572 56,992 $54.1 $18.3
ACT $5,152,791 100,462 $51.3 $26.5
NT $3,863,063 72,436 $53.3 $13.8
Total $450,729,483 8,556,689 $52.7 $18.9
Source: Medicare
The average cost per appointment in Australia is $52.7, with a gap payment
averaging $18.9. After adding the after-hours bulk-billing incentive of $6.2,
the total weighted average cost of the clinic appointment is $77.8.
A.4.1.2. Summary: Extended and after hours only clinics cost
The proportion of Australia’s total population in each jurisdiction has been
used to calculate the weighted average cost of a single clinic appointment of
$92.5. This cost has been determined for each outcome: referral to the
emergency department and treat and release, as well as between who
bears the cost; the patient, State Government, and Commonwealth
Government. Figure A.3: presents the breakdown.
52
Figure A.3: Per patient cost of after hours and extended hours clinics
Note: The cost of an assessment has been assumed to be the same as the treat and release cost
Table A.11: Total per patient cost of extended and after hours only clinics
Category Total cost Proportion of
patients
Weighted Average
Cost
Emergency department $368 4% $14.7
Treat and release $71.60 100% $71.6
After-hours bulk bill incentive $9.30 100% $6.2
Total weighted average patient cost $92.5
The Commonwealth Government is predominately responsible for primary
care and its funding through the MBS, including for consultations at
extended and after hours only clinics. However, State and Territory
Governments bare a proportion of the total weighted average patient cost
($14.70) as a proportion of patients are referred to emergency
departments, which State and Territory Governments are responsible for
funding. Additionally, this analysis identifies that patients also contribute
$18.90 per appointment on average relating to the gap payment.
A.4.2. Other costs
In terms of financial costs, after hours and extended hours clinics offer a
relatively inexpensive way to treat patients seeking care in after hours
periods. However, there are a range of other costs outside of the direct
financial cost to the Commonwealth Government, State and Territory
Governments and patients. These costs range from preferences regarding
ED
Treat and
releaseAfter and
extended
hours
clinics
$72
$368
100%
4%
53
where care is provided to the ability of patients to visit clinics and the
impact on doctors.
Firstly, extended and after hours only clinics offer GP services to those
patients that can attend they do not provide a solution to many patient
groups. For example, people with disabilities, parents and guardians with
multiple young children, or carers of frail elderly patients may find it difficult
to attend clinics for numerous reasons. Access Economics calculated the
‘replacement value’ of informal caregivers to be $31 per hour in 2010. This
cost could reasonably be factored in to the travel and waiting time taken up
by a clinic appointment.
Across Australia 17% of general practices provide 24-hour care through
phone triage services, in practice consultations, after hours home and ACF
visits, or home visits.31 This means that there is significantly less access to
GP services in after hours periods compared with in hours periods.
Finally, extended and after hours only clinics provide services to all patient
groups, not just those that are urgent. In some instances, this will result in
patients seeking non-urgent GP consultations, for example for a script
renewal, preventative check-ups or other convenience requests. The result
of this would be an increased cost to the health system given the additional
cost of the clinic when compared to an in hours GP. This reflects the trend
in preferences to access care out of normal business hours to match their
availability.
A.5. Healthdirect Helpline
Healthdirect Australia is a national organisation that provides 24/7 access to
health professionals and health information via a nurse triage helpline and a
range of online services. Callers to the Healthdirect Helpline speak with a
registered nurse who assesses their situation and advises next steps. The
service however does not diagnose and are not a replacement for face-to-
face care as such referrals to other services are high.
Healthdirect connects people with other services in the community by:
Taking non-emergency calls referred from ambulance services
Referring people to visit their doctor, pharmacist or other health service
Connecting people to the after hours GP helpline
Allowing people to locate their nearest services using the National
Health Services Directory.
A.5.1. Financial Costs
The first cost in the Healthdirect pathway is the Nurse Telephone triage.
There is limited publicly available data regarding the per call cost of a nurse
triage service. As such, a proxy calculated by the Royal Australian College
of General Practitioners for the My Aged Care Hotline of $45 has been used.
Healthdirect’s annual report 2014-15 shows that a number of patients are
referred from the nurse triage to the after hours GP helpline. For these
patients, Healthdirect incurs a second cost, as a GP discusses the patient’s
issue and provides advice over the phone. Although the cost of a GP is
higher than a nurse, the same cost per call applied in the nurse triage has
31 Jackson, C. (2015), Review of after hours primary health care
54
been applied due to a lack of data. This is considered a conservative
assumption.
Healthdirect Australia’s Annual Report 2014-15 also highlights the
proportion of out-of-hours callers that were advised to take each respective
pathway following conversation with a GP, through the After Hours GP
Helpline.
Patients are advised to take one of the following six pathways:
Self-care advice and see a doctor / health provider within normal
operating hours
On Call GP
On Call GP (no GP available – go to emergency department)
Self-care at home
Emergency department immediately
Other
Figure A.4: represents this pathway, the proportion of patients advised to
take each resultant pathway following the nurse triage call in 2014-15, in
addition to the respective cost of each pathway as previously calculated in
this analysis. For self-care and other, no cost has been assigned given the
limited information available. This means the result calculated is
conservative.
Figure A.4: Healthdirect Helpline pathway32
Note: The emergency department cost of $1,338 has been applied as this excludes ACF patients
transport cost, given it is unlikely that ACFs would be using the Healthdirect system.
Each of the pathways identified generates a cost proportionate to the
number of patients taking that pathway. Table A.12: shows the cost of the
32 On call GP cost is calculated using the relevant MBS urgent after hours attendance
item numbers and scaled up to include the gap payment and bulk billing incentive.
55
initial telephone consult, the weighted cost of each resultant pathway, and
the total weighted average cost of the service.
A.5.1.2. Summary: Healthdirect Cost
Table A.12: Healthdirect Helpline costs
Pathway Weighted Average Cost
Nurse triage $45
Own GP $12
Telephone GP consult $34
Self-care Not costed
Emergency department $63
Ambulance $102
Other Not costed
Total $256
The total weighted average cost of the Healthdirect pathway has been
calculated as $256. As seen in Table A.12: despite the relatively low
proportion of patients referred to them this cost is largely comprised of
ambulance services and emergency departments. This is because of the
high cost of those pathways.
The Commonwealth Government funds the Healthdirect Helpline service.
However the total cost of the service incorporating all follow-on pathways
takes into account costs passed on to the State and Territory Governments
and patients as identified in the analysis of each individual pathway.
A.5.2. Other Costs
A Medical Journal of Australia study into the Healthdirect phone service
revealed that many callers do not comply with the advice provided to them.
“More than half of those who attended Royal Perth Hospital’s ED after
contacting Healthdirect did so despite being given advice not to attend”.
This raises the issue that the service becomes an additional cost to the
health system in adding an extra step to those patients with the outcome,
i.e. an emergency department presentation, being the same. It should be
noted that this additional cost has not been factored into the analysis and
therefore assumes that patients comply with the advice provided.
A.6. Hunter GP Access
Hunter GP Access After Hours provides free after hours medical care and
advice to people of the Newcastle, Lake Macquarie and Maitland areas on
weeknights, weekends and public holidays. Whilst the clinics are located
within hospitals it is similar to other out of hours services in that the first
step is a telephone triage and advice system, the Patient Streaming Service
(PSS).
Following a call to the PSS, a patient will be redirected to 1 of 7 alternative
pathways:
Hunter GP Access Clinic Appointment
Emergency department
Healthdirect
56
Visit own GP in hours
Other (including ambulance)
Self-care
On call GP.
In addition to the 7 outcomes listed a proportion of the patients that are
referred on to the Hunter GP Access Clinic, 4%, will then be redirected to
the emergency department.
A.6.1. Financial Costs
The cost of the Hunter GP Access Pathway is created by the initial telephone
consult as well as the potential resultant Hunter GP Access Clinic
appointment. As with the Healthdirect pathway, a proxy of $45 has been
used for the telephone consultation given the limited data available to
calculate this. Similarly the clinic cost of $53 (rounded) has been pulled
from the calculation made in the After Hours Clinic pathway given the clinics
will generate fees from the same MBS item numbers.
The Hunter GP Access service pathway resulting from the telephone consult
is shown in Figure A.5:. The diagram also highlights the proportion of
patients that were redirected to each pathway according to a May 2015
Cost Study of GP Access After Hours conducted by Hunter Research
Foundation, and the corresponding cost of the next pathway.
Figure A.5: Hunter GP Access pathway
Summary: Hunter GP Access
Once the respective costs and proportionate representations are applied to
one another, a weighted average cost to each of the other services
generated by the Hunter GP Access can be determined. Table A.13: shows
the average cost of one patient calling the initial PSS system, as well as the
weighted cost of each of the resultant pathways from it.
57
Table A.13: Hunter GP Access costs
Pathway Weighted Average Cost
Telephone Consult $45
Clinic appointment $32
Emergency department portion of a clinic appointment $9
Emergency department $43
Health Direct $32
Own GP in hours $3
Other Not costed
Self-care Not costed
On call GP $5
Total $169
The total weighted average cost of the Hunter GP Access service is $169. As
can be seen Table A.13: this cost is largely made up by cost of the
telephone consult and the clinic itself. The main other services it generates
a cost to are the emergency department, $52 ($9 + $43), and Healthdirect,
$32. This outcome is slightly conservative as the ‘other’ and ‘self-care’
components are too vague to be quantified, although these do only make
up 5.8% of the referral outcomes and would therefore likely be minimal.
A.7. After hours home and ACF visits
After hours home and ACF visits provide fully bulk billed after-hours home
visits to urgent primary care patients. Following the home visit a clinical
report is sent to the patient’s primary GP to ensure continuity of care.
A.7.1. Financial cost
Patients that receive after-hours home visits are either treated and released
at the end of that episode of care or are referred to a hospital emergency
department. The cost of the emergency department has been factored in,
as it is a direct result of the home visit referral.
According to the National Home Doctor Service 97% of its home visits result
in a patient being released from care, with 3% being referred on to a
hospital emergency department. Determining these proportions enables us
to calculate the per patient cost of after hours home and ACF visits by
factoring in the proportionate cost of the emergency department. The cost
of an emergency department presentation has been quantified below in the
emergency department pathway ($368 per patient), and used in
determining the total weighted average cost of this pathway. The cost by
patient cohort has not been separated due to data limitations.
The average cost of After hours home and ACF visits has been calculated
using 2015-16 activity and cost data for all relevant Medicare Benefits
Schedule items supplied. This included all commonly used after-hours
Medicare Benefit Schedule items for GPs, as can be seen in Appendix C. The
after-hours bulk billing incentive of $6.2 was added, as it is an incentive to
bulk billing appointments only. Table A.14: shows the total Medicare
expenditure, total activity, and Medicare cost per appointment.
58
Table A.14: After hours home and ACF visits cost by State and Territory
Jurisdiction Total Medicare
expenditure ($)
Total activity Medicare cost per
appointment
NSW $72,597,432 695,715 $104.35
VIC $75,277,630 697,654 $107.9
QLD $88,953,508 762,198 $116.71
WA $27,288,371 231,177 $118.04
SA $42,431,746 367,908 $114.79
TAS $4,365,473 39,040 $111.82
ACT $3,491,377 29,990 $116.42
NT $1,264,592 15,638 $80.87
Total $315,470,129 2,839,320 $111.12
Source: Medicare
The average cost per appointment in Australia is $111.1, after adding the
after-hours bulk billing incentive of $6.2 the total weighted average cost of
the home visit is $117.2.
A.7.1.2. Summary: After hours home and ACF visits cost
When factoring in the additional $11.04 to account for the proportion of
patients that are referred on to an emergency department ($368 x 3%) the
total cost a single home visit of $128.36 is determined. Table A.15: shows
the breakdown of cost.
Table A.15: Total per patient cost of After hours home and ACF visits
Category Total cost Proportion of
patients
Weighted Average
Cost
Emergency department $368 3% $11.0
Treat and release $111.1 100% $111.1
After-hours bulk bill incentive $6.2 100% $6.2
Total weighted average patient cost $128.4
Note: After hours bulk-billing incentive has been applied consistently as a conservative estimate.
Since the Commonwealth Government is predominately responsible for
primary care and its funding through the MBS, including for After hours
home and ACF visits consultations it funds $117.3 of the $128.4 cost
($111.1 + $6.2). However, State and Territory Governments bare a
proportion of the total weighted average patient cost ($11.04) as a
proportion of patients are referred to emergency departments, which State
and Territory Governments are responsible for funding
A.7.2. Other costs
As with all care pathways a proportion of patients that use after hours home
and ACF visits do so inappropriately. A criticism aimed at this pathway is
59
that there is an element of cost increase to the overall system as some
patients use the service when they were able to access an alternative
pathway in hours, or visit an Extended and after hours only Clinics at a
lower cost, however they choose to use After hours home and ACF visits for
the convenience provided.
60
Appendix B: Patient pathways analysis
including admitted
patient costs
The patient pathway analysis in Appendix A has considered the cost to
emergency departments of patients self-presenting or arriving by
ambulance who are not admitted. A proportion of patients in each pathway
either directly or indirectly present at emergency departments, meaning
that including the cost of admitted patients will change the cost of all
patient pathways. This Appendix quantifies the average cost of an
emergency department presentation (admitted) and then applies it to the
other pathways to determine its impact.
The cost of each pathway including the cost of admitted patients has been
calculated separately in Appendix B to understand the potential overall
quantum of cost associated with each pathway. Appendix A is consistent
with AIHW’s definition of a potentially preventable GP-type patient.
It is important to note that the actual cost of the admission is not included
in the cost presented below – the cost of admission is in addition. The
emergency department cost for admitted patients represents the cost of
care in the emergency department for patients who are subsequently
admitted.
B.1. Emergency department (with admitted patients)
Patient-level emergency department data containing the details of
emergency department presentations in Australia has been used to
determine the outcomes of patients that:
Seek care in after hours periods
Are triaged as category 4 or 5
Did not arrive by ambulance – these patients are considered in the
ambulance pathway analysis.
At a high-level, the outcomes of patients presenting at emergency
departments can be classified into three categories:
Admitted into the hospital
Not admitted into the hospital: received treatment and sent home, they
did not wait, were seen and left at their own risk, or died before being
admitted
Transferred to another care facility (e.g. hospital).33
33 A small number of patients die before arriving at the emergency department
61
The cost and likelihood of each of these outcomes is different for each
cohort. Admitted patients usually require more emergency department
resources (e.g. medical supplies and time from doctors and nurses), which
costs more than patients who are not admitted. Some type of patients are,
on average, more likely to be admitted than others. The higher the
proportion of patients in a certain cohort that are admitted, the higher the
overall cost that patient cohort imposes on emergency departments. This
means it is important to consider admitted and non-admitted costs by
patient cohort.
The same costs used to calculate the cost of an emergency department
presentation in Section A1 have been used. Presented in Table B.1: below is
the relevant UDG costs for triage categories 4 and 5 and patient cohort,
along with the transfer cost, which has been calculated by taking the
average patient transfer cost of each State and Territory.
Table B.1: Financial cost of emergency department outcomes by triage and age
cohort
Triage category 0 – 65 years 79+ years Transfer (all
age cohorts)
Admit Did not admit Admit Did not admit
Category 4 $763 $369 $923 $447 $382
Category 5 $577 $240 $698 $291 $382
Source: Independent Hospital Pricing Authority (2016), Emergency Department costs
The second component of this analysis is to determine how often patients in
each cohort are admitted. The patient-level emergency data provided by
the AIHW has been used to determine the proportion of each patient cohort
that is admitted. The data set isolates presentations during after hours
periods for triage categories 4 and 5. The results of the analysis are in
Table B.2:.
Table B.2: Proportion of patients admitted and transferred by triage category
and cohort
Triage category Cohort Admit Did not admit Transfer
Category 4 Baby / small child 6.0% 93.7% 0.3%
Typical adult 11.4% 88.1% 0.5%
Elderly, living at home
27.1% 71.8% 1.1% Elderly, living in a ACF
Category 5 Baby / small child 3.0% 96.8% 0.2%
Typical adult 10.2% 89.4% 0.4%
Elderly, living at home
4.0% 95.8% 0.2% Elderly, living in a ACF
62
Source: 2014/15 AIHW emergency department presentation data
Note: Data were not available to determine the difference between patients aged 75+ and those
who arrived from ACFs so the same figures have been applied for the purpose of this analysis.
As would be expected, the cohorts relating to elderly patients have
substantially higher admission rates when presenting with a category 4
condition. However, the typical adult cohort (i.e. patients aged between 20
and 60 years old) had a higher admission rate than elderly patients living at
home or in ACFs when triaged as category 5. Conversely, when considering
non-admitted patients 8% of the typical adult cohort either did not wait to
be seen, or left at their own risk, this is in contrast to 15% of elderly
patients living at home or in ACFs. This has contributed to the admitted rate
being higher for typical adults relative to elderly patients for triage category
5.
B.1.2. Summary: Emergency department presentation costs,
including admitted patient costs
Figure B.1: and Figure B.2: summarise the analysis undertaken for triage
categories 4 and 5 respectively. The costs for admitted and non-admitted
category 4 patients differ greatly between the patient cohorts. The baby /
small child and typical adult cohorts are $160 and $78 less per patient than
the two elderly patient cohorts respectively. Figure B.2: provides a similar
outcome for category 5 patients whereby admitted patients cost $121 less
for the baby / small child and typical adult cohorts, and non-admitted
patients $51 less.
The cost differences identified between cohorts are attributable to various
factors. Firstly, elderly patients often present with multiple co-morbidities.
Such patient types cost disproportionately more than those presenting with
one illness. For example, a 2015 study in the United States of America
concluded that the average cost of treating patients with five illness
complexities is ten times higher than those with one illness complexity.34
Figure B.1: Emergency department triage category 4 presentation cost
34 Acumen (2014), Challenges in controlling Medicare spending: Treating high complexity patients
Transfer$382
Did not
admit $369
Admit$763
Baby / small child
Typical adult (20 – 60 years old)
Elderly person living
at home
Elderly person living
in a RACF
$393 $414 $573Total (weighted
average cost)
Emergency
department
6.0%
93.7%
0.3%
11.4%
88.1%
0.5%
27.1%
71.8%
1.1%
Emergency
department
Transfer$382
Did not
admit $447
Admit$923
63
Figure B.2: Emergency department triage category 5 presentation cost
Figure B.1: and Figure B.2: also identify the (weighted) average cost per
patient for triage categories 4 and 5. By weighting this by the proportionate
activity of each patient cohort, an overall (weighted) average for each
category is found:
Category 4: $573
Category 5: $307.
Patients classified as triage category 4 cost 62% more than patients
classified as triage category 5. This is due to higher admission rates, and
the higher cost of those patients who are subsequently admitted.
Table B.3: shows the cost per patient presentation by patient cohort.
Elderly people pose a greater cost when presenting to emergency
departments. As anticipated, the analysis determined that elderly patient
cohorts are substantially more expensive than the baby /small child and
typical adult cohorts. This is primarily due to the factors previously outlined
regarding admission rates and patient complexity, however specifically
relevant to elderly patients living in ACFs, is the cost of transporting
patients back to ACFs, which has been factored into the cost of the patient
cohort. It has been assumed that all elderly patients from ACFs require
ambulance assistance from the emergency department back to the ACF.
By weighting these outcomes by the proportionate activity of each triage
category, the overall per patient cost of an emergency department
presentation is $468 for the patient cohorts considered in this analysis.
Transfer$382
Did not
admit $240
Admit$577
Baby / small child
Typical adult (20 – 60 years old)
Elderly person living
at home
Elderly person living
in a RACF
$251 $276 $307Total (weighted
average cost)
Emergency
department
3.0%
96.8%
0.2%
10.2%
89.4%
0.4%
4.0%
95.8%
0.2%
Emergency
department
Transfer$382
Did not
admit $291
Admit$698
64
Table B.3: Per patient cost by cohort
Cohort Per patient cost
Baby / small child $371
Typical adult $350
Elderly, living at home $484
Elderly, living in a ACF $823
All cohorts $468
B.2. Ambulance
As discussed, the cost of the ambulance pathway comprises two costs:
Ambulance transport and treatment
The emergency department, where a transport to the emergency
department occurs.
The cost of the ambulance transport and treatment has been quantified in
section A2 at $957 on average. This cost is the same in the context of
considering admitted patients as the key difference is the cost between an
admitted and non-admitted patient at an emergency department.
As above, the cost of an emergency department has been quantified
including admitted patients. That cost excluded the outcomes of patients
who arrived by ambulance. This section quantifies the cost associated with
patients who arrived by ambulance to emergency departments in after
hours periods and includes the outcomes and costs of those patients who
were admitted or transferred.
B.2.1. Hospital emergency departments
For those patients transported to emergency departments, there is an
additional cost for treating them there. This has been quantified using the
same methodology as applied to the emergency department pathway.
However, the AIHW emergency department data set was used to isolate the
outcomes of those patients who arrived by ambulance in after hours
periods. The results are shown for category 4 and 5 in Figure B.1: and
Figure B.4: respectively.
65
Figure B.3: Category 4 ambulance patients
Figure B.4: Category 5 ambulance patients
Regardless of the cohort, triage category 4 patients are more expensive to
treat than triage category 5 patients, the largest difference is seen with
admitted elderly patients costing $225 more.
Similarly, category 4 patients would be expected to be admitted more
frequently than category 5 patients are. This is the case in cohorts 1, 3 and
4, with the largest increase in admission rate of 49% seen in elderly
patients. However, somewhat surprisingly cohort 2 patients were admitted
more frequently when presenting as a triage category 5 patient, 46.1%
compared to 27.7%.
Table B.4: shows the total weighted cost of the two ambulance components
by patient cohort.
66
Table B.4: Per patient cost by cohort
Triage Category Cohort ED Component Ambulance Component Total
Category 4 Baby / small child $436 $957 $1,393
Typical adult $480 $957 $1,437
Elderly, living at home $739 $957 $1,696
Elderly, living in a ACF $1,140 $957 $2,097
Category 5 Baby / small child $293 $957 $1,250
Typical adult $400 $957 $1,357
Elderly, living at home $347 $957 $1,304
Elderly, living in a ACF $748 $957 $1,705
All cohorts weighted average $591 $957 $1,548
B.3. Impact on other patient pathways
Adjusting the change in the cost of the emergency department to all the
other pathways increases the average cost of those pathways. This is
because the cost of admitted patients are higher. Table B.5: compares the
cost of each pathway including and excluding admitted patient costs.
Table B.5: Comparison of patient pathway costs that include and exclude
admitted patient costs
Pathway Weighted average patient
pathway cost, excluding ED
costs of admitted patients
Weighted average patient
pathway cost, including ED
costs of admitted patients
Emergency department $368 $458
Ambulance $1,351 $1,548
Extended and after hours only
clinics $93 $97
Healthdirect $256 $293
Hunter GP Access Scheme $169 $215
After hours home and ACF visits $128 $128
67
Appendix C: NAMDS members
NAMDS is the industry body representing after hours home and ACF visits
organisations in Australia. The NAMDS members are:
Call the Doctor Pty Ltd
Canberra After Hours Locum Medical Services
Dial A Doctor (and related entities)
DoctorDoctor Pty Ltd (and related entities)
House Call Doctor Pty Ltd
National Home Doctor Service (and related entities)
Newcastle After Hours Medical Service
Perth After Hours Medical Service
Sydney Medical Services Co-Operative
WAMDS
Wollongong Medical Service Co-Operative
68
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69
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